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This is information about requirements when you’re paying Medicare benefits for referred or requested services. You may need more information if you’re accepting a referral or request.
What you need to know
To bill a referred or requested service to Medicare, specialist referrals or requests for diagnostic imaging and pathology services must comply with all of these:
- the Health Insurance Act 1973
- Health Insurance Regulations 2018
- Health Insurance (Pathology Services Table) Regulations 2020
- Health Insurance (Diagnostic Imaging Services Table) Regulations (No. 2) 2020
- Health Insurance (General Medical Services Table) Regulations (No. 2) 2020.
Referrals for specialist treatment
Patient referrals to a specialist or consultant physician for treatment, not including general practitioners, need to meet certain conditions. The referral must include all of the following:
- relevant clinical information about the patient’s condition for investigation, opinion, treatment and management
- the date of the referral
- the signature of the referring practitioner.
Referrals don’t need to be made out to a certain specialist or consultant physician.
If you’re referring a patient, you should let them choose where to present the referral. This also applies to electronic referrals.
Single course of treatment
A referral covers a single course of treatment for the referred condition. A single course of treatment is an initial attendance at the specialist or consultant physician. It includes subsequent attendances for the continuing management until the patient is referred back to the referring practitioner.
A new referral doesn’t always mean a new course of treatment.
If a referral is for continuing management of a condition, the specialist or consultant physician must bill subsequent attendance items. However, you can bill an initial attendance item if it meets all the following:
- the referring practitioner decides the patient’s condition needs to be reviewed
- the patient is seen by the specialist or consultant physician after the expiry of the last referral
- the patient was last seen by the specialist or consultant physician more than 9 months earlier.
If the patient has a new or unrelated condition, the specialist can start a new course of treatment if there is a new referral in place.
Referral periods from a GP to a specialist
A referral from a general practitioner (GP) to a specialist lasts 12 months, unless noted otherwise. The referral starts from the date the specialist first meets the patient, not the date issued.
If a patient needs continuing care, GPs can write a referral beyond 12 months or for an indefinite period.
If a patient on an indefinite referral has a new or unrelated condition, the GP must issue a new referral for that condition.
Referral periods from a specialist to another specialist
Referrals from specialists and other consultant physicians are valid for 3 months unless it's for an admitted patient.
Referrals for admitted patients are valid for 3 months or the duration of admission, whichever is longer.
Lost, stolen or destroyed referrals
A written referral that is lost, stolen or destroyed is valid for only one attendance by the patient. You must get a valid referral before you can bill any subsequent services. The account, receipt or assignment form must include all of the following:
- the referring medical provider’s name
- practice address or provider number of the referring medical provider (if known)
- the words ‘lost referral’.
Read about Referral of Patients To Specialists Or Consultant Physicians on the Department of Health website.
Referrals for allied health services
You can refer patients for allied health services under the following initiatives:
- Chronic Disease Management
- Better Access to psychiatrists, psychologists and general practitioners
- Better Start for Children with Disability
- Eating disorder treatment and management
- Helping Children with Autism program
- follow-up services after Aboriginal and Torres Strait Islander health assessments.
Requests for diagnostic imaging services
Requests for diagnostic imaging services must have:
- the requesting practitioner’s full name, provider number or practice address
- the date of the request
- a description of the services requested.
Patients can choose a health professional and don’t need to give a request to a specific practice. This also applies to electronic requests.
Read more about Requests for R-type Diagnostic Imaging Services on the Department of Health website.
Requests for pathology services
Requests for pathology services must have all of the following:
- the patient’s name and address
- the patient’s hospital status
- the requesting practitioner’s full name, provider number and practice address
- a description of the services requested
- the date of the request.
Patients can choose a health professional if there’s no clinical need for a specific pathologist to do the service. This also applies to electronic requests.
Read more about Pathology services - Form of Request on the Department of Health website.
Electronic referrals and requests
You must comply with the Electronic Transactions Act 1999 when sending referrals and requests electronically between third parties. Section 10 has more information about electronic signatures.
You must save, store and retain access to electronic referrals or requests so you can retrieve them unaltered. Your records may need to be checked in the event of an audit.