Dental Benefits Rules 2014

Link to law: https://www.comlaw.gov.au/Details/F2014L01748

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Dental Benefits Rules 2014
Dental Benefits Act 2008
I, PETER DUTTON, Minister for Health, make these Rules under subsection 60(1) of the Dental Benefits Act 2008.
Dated             2010
Dated 11/12/14
PETER DUTTON
Minister for Health
Contents
1    Name of Rules                                                                                    3
2    Commencement                                                                                  3
3    Revocation                                                                                         3
4    Definitions                                                                                          3
5    Dental Benefits Schedule                                                                    4
6    Dental providers (Act, s 6)                                                                   4
7    Persons eligible to render services on behalf of dental providers (Act, s 7 (a))           5
8    Particulars to be recorded (Act, s 17 (2))                                              5
8A Dental Benefits not payable unless conditions specified  (Act, s 18 (2) (e))    5
9    Classes of persons who satisfy the means test (Act, s 24 (1) (d))          6
10  Issuing more than 1 voucher for a person for a calendar year (Act, s 27 (5))   6
11  When vouchers are not required to be issued (Act, s 29)                       7
12  Period of effect of voucher (Act, s 31)                                                 7
13  Persons to whom the vouchers are to be issued (Act, s 32 (c))              7
14  Monetary limit on dental benefits (Act s. 62 (2) (c))                               9
15  Informed Financial Consent  (Act s. 62(2))                                            9
16  Clinical records                                                                                 10
17  Limitation on number of certain services                                             11
18  Limitation on provision of certain services                                          11
19  Limitation on Diagnostic Services                                                      11
20  Limitation on Preventative Services                                                    11
21  Limitation on Periodontic Services                                                     11
22 Limitation on Oral Surgery                                                                  11
23 Endodontic Services                                                                         12
24 Restorative Services                                                                          13
25 Prosthodontics                                                                                 13
26 Application of item 88455                                                                  13
27 Limitation on items 88521 and 88531                                                  13
28 Application of Item 88572                                                                  14
29 Application of item 88911                                                                  14
Schedule 1                  Dental Benefits Schedule                                                                 15
Schedule 2                  Eligibility of Dental Services rendered by or on behalf of or under an arrangement with a State or internal territory                                                                           23
Schedule 3                  Benefit limits                                                                                   23
 
 
    
1              Name of Rules
                These Rules are the Dental Benefits Rules 2014.
2              Commencement
                These Rules commence on 1 January 2015.
2A           Authority
                These Rules are made under the Dental Benefits Act 2008.
3              Revocation
                The Dental Benefits Rules 2013 are revoked.
4              Definitions
                In these Rules:
Act means the Dental Benefits Act 2008.
carer payment has the meaning given by Part 2.5 of the Social Security Act 1991.
dental hygienist means a person who has general registration in the dental hygienists division of the dental profession under a law of a State or Territory.
dental prosthetist means a person who has general registration in the dental prosthetists division of the dental profession under a law of a State or Territory.
dental provider has the meaning given in rule 6.
dental therapist means a person who has general registration in the dental therapists division of the dental profession under a law of a State or Territory.
disability support pension has the meaning given by Part 2.3 of the Social Security Act 1991.
double orphan pension has the meaning given by Part 2.20 of the Social Security Act 1991.
FTB(A) person has the same meaning as in section 24 of the Act.
FTB recipient has the same meaning as in section 24 of the Act.
medicare number has the same meaning as in section 84 of the National Health Act 1953.
MRCAETS means the Military Rehabilitation and Compensation Act Education and Training Scheme.
Note Military Rehabilitation and Compensation Act Education and Training Scheme 2004 is a legislative instrument.
oral health therapist means a person who has general registration in the oral health therapists division of the dental profession under a law of a State or Territory.
parenting payment has the meaning given by the definition of parenting payment in section 18 of the Social Security Act 1991.
partner has the same meaning as in the Social Security Act 1991.
provider number has the same meaning as in the Health Insurance Regulations 1975.
public sector dental provider means:
                (a)    a dental provider employed by, contracted to, or providing dental services under an arrangement with:
                          (i)    the Commonwealth; or
                         (ii)    a State; or
                        (iii)    an internal Territory; or
                        (iv)    a local governing body; or
                         (v)    an authority established by a law of the Commonwealth, a law of a State or a law of an internal Territory; or
               (b)    a dental provider on whose behalf another dental provider provides dental services under an arrangement with a body mentioned in subparagraph (a) (i), (ii), (iii), (iv) or (v).
receive, for disability support pension, parenting payment, special benefit, carer payment and double orphan pension, has the meaning given by section 23 of the Social Security Act 1991.
relevantly provided, for a dental service, means provided as a service for which dental benefit is payable under the Act. 
special benefit has the meaning given by Part 2.15 of the Social Security Act 1991.
VCES means the Veterans’ Children Education Scheme.
Note 1   Veterans’ Children Education Scheme is a legislative instrument.
Note 2   For the definitions of other expressions used in these Rules, see the Act.
5              Dental Benefits Schedule
              For subsection 61 (1) of the Act, the Dental Benefits Schedule is set out in Schedule 1.
6              Dental providers (Act, s 6(2)(a))
             A dental practitioner is not a dental provider in relation to a dental service if the dental practitioner has not been allocated a provider number by the Chief Executive Medicare.
7              Persons eligible to render services on behalf of dental providers (Act, s 7 (a))
              For the Dental Benefits Schedule:
                (a)    a dental service may be rendered on behalf of a dental provider by the following classes of persons:
                          (i)    dental hygienists;
                         (ii)    dental therapists;
                        (iii)    dental prosthetists; and
                        (iv)    oral health therapists;
               (b)    a dental service may be rendered on behalf of a public sector dental provider by another public sector dental provider.
8              Particulars to be recorded (Act, s 17 (2))
Patient billed services
     (1)     For the payment of dental benefits listed in the Dental Benefits Schedule, the following particulars must be recorded on the account or receipt:
               (a)     the patient’s name;
               (b)    the date of the service;
                (c)    the item number in the Dental Benefits Schedule that corresponds to the service;
               (d)    the dental provider’s name and provider number;
                (e)    the amount charged for the service, total amount paid, and any amount outstanding for the service.
Bulk billed services
     (2)     If there is an assignment of dental benefits for an item under the Dental Benefits Schedule, the following particulars must be recorded on the assignment of benefit form:
                (a)    the patient’s name;
               (b)    the date of the service;
                (c)    the item number in the Dental Benefits Schedule that corresponds to the service;
               (d)    the dental provider’s name and provider number;
                (e)    the amount of the dental benefit being assigned to the dental provider.
8A           Dental benefits not payable unless conditions satisfied (Act, s 18 (2))
     (1)     A dental service rendered by or on behalf of or under an arrangement with a State or internal Territory is not eligible for dental benefits unless:
                (a)    the State or internal Territory in which the service was performed is mentioned in column 1 of Schedule 2; and
               (b)    the service is provided on or before the date in column 2 of schedule 2 pertaining to that State or internal Territory.
     (2)     Despite subrule (1) the Minister may direct that a dental service rendered by or on behalf of or under an arrangement with a State or internal Territory is eligible for dental benefits.
     (3)     A dental benefit is not payable in respect of a dental service unless, at the time the dental service is rendered, the eligible dental patient to whom the dental service is rendered is an eligible person.
9              Classes of persons who satisfy the means test (Act, s 24 (1) (d))
For paragraph 24 (1) (d) of the Act, a person satisfies the means test, in a calendar year, if in the calendar year:
                (a)    both:
                          (i)    section 23 of the Act applies to the person; and
                         (ii)    the person is receiving any of the following payments:
(A)   disability support pension;
(B)   parenting payment;
(C)   special benefit;
(D)   carer payment;
(E)   payments made under VCES or MRCAETS, if the person is a person mentioned in paragraph (c), in column 3, of item 2 of the table in subsection 22A (1) of A New Tax System (Family Assistance) Act 1999; or
               (b)    both:
                          (i)    section 23 of the Act applies to the person; and
                         (ii)    the person’s parent, carer or guardian is receiving parenting payment or double orphan pension for the person; or
                (c)    both:
                          (i)    section 23 of the Act applies to the person; and
                         (ii)    the person’s partner is receiving parenting payment; or
              (d)  both:
                          (i)    section 23 of the Act applies to the person; and
                         (ii)    another person is receiving payments under VCES or MRCAETS on behalf of the person where that other person is a person referred to in paragraph (c), in column 3, of item 2 of the table in subsection 22A(1) of A New Tax System (Family Assistance) Act 1999.
10            Issuing more than 1 voucher for a person for a calendar year (Act, s 27 (5))
     (1)     For the Dental Benefits Schedule, more than 1 voucher may be issued for a person for a calendar year if:
                (a)    the person is an FTB(A) person for whom there is more than 1 FTB recipient; or
               (b)    the person has more than 1 parent, carer or guardian who is receiving double orphan pension for the person; or
                (c)    the person’s voucher has been lost or destroyed, or the person has not received it.
     (2)     For paragraphs (1) (a) and (b), the Chief Executive Medicare may issue 2 vouchers for the person.
     (3)     For paragraph (1)(c), the Chief Executive Medicare may issue a replacement voucher if the person asks the Department of Human Services for a replacement voucher, stating whether the voucher was lost, destroyed or not received.
11            When vouchers are not required to be issued (Act, s 29)
     (1)     The Chief Executive Medicare is not required to issue a voucher for a calendar year for a person who qualifies for the voucher if:
                (a)    the person has not been assigned a medicare number; or
               (b)    both:
                          (i)    written consent has not been provided by a person mentioned in sub-subparagraph (ii) (A) or (B) for the Department of Veterans’ Affairs to provide his or her personal information to the Department of Human Services for use in the administration of this Act; and
                         (ii)    either:
(A)   the person is eligible for payments under VCES or MRCAETS; or
(B)   another person is receiving payments under VCES or MRCAETS on behalf of the person; or
                (c)    the person has reached the cap set for the relevant 2 year period.
     (2)     In this rule:
              cap and relevant 2 year period have the meanings given in rule 14.
12            Period of effect of voucher (Act, s 31)
              For the Dental Benefits Schedule:
                (a)    a voucher for the calendar year commencing on 1 January 2014 takes effect on and from that date and remains in effect until the end of 31 December 2014; and
               (b)    a voucher for a calendar year commencing on 1 January of a subsequent year takes effect at the beginning of 1 January of that year and remains in effect until the end of 31 December of that year.
13            Persons to whom the vouchers are to be issued (Act, s 32 (c))
              For the Dental Benefits Schedule, a voucher is to be issued:
                (a)    if an eligible dental patient is receiving youth allowance — to the eligible dental patient; or
               (b)    if an eligible dental patient is receiving a payment under the ABSTUDY scheme, or another person or an institution is receiving such a payment in respect of the eligible dental patient:
                          (i)    if the eligible dental patient applied for the payment — to the  eligible dental patient; or
                         (ii)    if the eligible dental patient’s parent or guardian applied for the payment — to the parent or guardian who made the application; or
                        (iii)    if an institution applied for the payment — to the institution that made the application; or
                (c)    if an eligible dental patient is an FTB(A) person:
                          (i)    if there is 1 FTB recipient for the person — to the FTB recipient for the person; or
                         (ii)    if there is more than 1 FTB recipient for the person — to the FTB recipient with the highest percentage of care arrangements for the person; or
                        (iii)    if there is more than 1 FTB recipient for the person and the FTB recipients have equal care arrangements for the person — to a maximum of 2 FTB recipients with the most current records of entitlement; or
               (d)    if an eligible dental patient is receiving a payment mentioned in subparagraph 9(a) — to the eligible dental patient; or
                (e)    if an eligible dental patient’s parent, carer or guardian is receiving parenting payment for the eligible dental patient — to the parent, carer or guardian receiving the payment; or
                (f)    if an eligible dental patient’s carer or guardian is receiving double orphan pension for the eligible dental patient:
                          (i)    if there is 1 carer or guardian receiving the pension for the eligible dental patient — to the carer or guardian receiving the pension; or
                         (ii)    if there is more than 1 carer or guardian receiving the pension for the eligible dental patient — to the carer or guardian receiving the pension with the highest percentage of care arrangements for the eligible dental patient; or
                        (iii)    if there is more than 1 carer or guardian receiving the pension for the eligible dental patient and those carers and/or guardians have equal care arrangements for the eligible dental patient — to a maximum of 2 carers or guardians receiving the pension with the most current records of entitlement; or
               (g)    if an eligible dental patient is a person mentioned in paragraph 9(c) — to the partner receiving the payment; or
               (h)    if an eligible dental patient is a person mentioned in paragraph 9(d) — to the person receiving the payment on behalf of the eligible dental patient.
14            Monetary limit on dental benefits (Act s. 62 (2) (c))
     (1)     The total of dental benefit payable in respect of dental services provided to an eligible dental patient must not exceed the specified monetary limit for the relevant 2 year period.
     (2)     In this rule:
              specified monetary limit is the cap.
     (3)     An eligible dental patient shall be subject to a cap as listed in Schedule 3.
     (4)     The cap is the maximum amount of dental benefits paid for services listed in the Dental Benefits Schedule provided to the eligible dental patient within a relevant 2 year period referred to in column 1 of Schedule 3.
     (5)     In this rule:
              relevant 2 year period, for an eligible dental patient, has the meaning given by subrules (6), (7), (8) and (9).
     (6)     If:
                (a)    an eligible dental patient received a dental service on or after 1 January 2014; and
               (b)    the dental service is the first dental service that the eligible dental patient has received on or after 1 January 2014;
               the calendar year in which the eligible dental patient received that first dental service and the following calendar year is a relevant 2 year period for the eligible dental patient.
     (7)     Once the limit set by the cap for a relevant 2 year period has been reached the eligible dental patient will not receive any more benefits in that relevant 2 year period.
     (8)     Once a relevant 2 year period has ended, the first time thereafter that a dental service listed in the Dental Benefits Schedule is rendered to an eligible dental patient it will trigger the commencement of a subsequent relevant 2 year period.
     (9)     If there is no cap listed in Schedule 3 for the relevant 2 year period in which a service is provided, the cap for the most recent 2 year period listed in that Schedule shall apply.
Example 1
A person who first receives a dental service on 25 January 2014 will be eligible for not more than $1,000 in dental benefits for all dental services provided to the person in 2014 and 2015.
A further relevant 2 year period commences for that person in the calendar year when the person first receives a dental service on or after 1 January 2016.
15            Informed financial consent (Act, s 62 (2))
     (1)     An item in the Dental Benefits Schedule applies to a dental service only if a dental provider:
                (a)    obtains consent to provide the dental service from the eligible dental patient or a person able to consent on his/her behalf and informed financial consent to costs from the person who incurs the dental expenses for that dental service before providing any item in the Dental Benefits Schedule; and then:
               (b)    records the consent to treatment and costs; and
                (c)    obtains the appropriate signature or signatures on a patient consent form.
     (2)     In respect of a dental service where there has been an agreement under section 12 of the Act between the eligible dental patient and the dental provider to assign dental benefits, subrule 15(1) is met if a ‘Bulk Billing Patient Consent Form’ was executed on the same day as the service was provided, or on an earlier day in the same calendar year.
     (3)     In respect of any dental service, subrule 15(1) is met if a ‘Non-Bulk Billing Patient Consent Form’ was executed on the same day as the service was provided. For the avoidance of doubt, this subrule does not apply to a service if subrule 15(1) is met under subrule 15(2) in respect of that service.
     (4)     The patient consent form executed under subrule 15(2) must be made in the form published by the Department and described as the ‘Bulk Billing Patient Consent Form’, as existing on 1 January 2014.
Note:  The form is available on the internet – see http://www.health.gov.au/dental
Note: Section 25C of the Acts Interpretation Act 1901 provides that where an Act prescribes a form, then strict compliance with the form is not required and substantial compliance is sufficient.
     (5)     The patient consent form executed under subrule 15(3) must be made in the form published by the Department and described as the ‘Non-Bulk Billing Patient Consent Form’, as existing on 1 January 2014.
Note:  The form is available on the internet – see http://www.health.gov.au/dental
Note: Section 25C of the Acts Interpretation Act 1901 provides that where an Act prescribes a form, then strict compliance with the form is not required and substantial compliance is sufficient.
     (6)     Subrules 15(1)(b) and 15(1)(c) do not apply in respect of a dental service if an ‘extenuating circumstance’ applies in respect of that service.
     (7)     For this rule, extenuating circumstances are as determined in the ‘Ministerial guidelines for the Child Dental Benefits Schedule: Extenuating circumstances for informed financial consent’ as made by the Minister and as amended from time to time.
Note 1:  The guidelines are available on the internet – see http://www.health.gov.au/dental
Note 2:  Section 60 of the Act provides that despite anything in the Legislative Instruments Act 2003, the Rules may make provision in relation to a matter by applying, adopting or incorporating any matter contained in any other instrument or writing as in force or existing from time to time. 
16            Clinical records
     (1)     Eligible dental providers must keep clinical records, including relevant patient consent forms for the provision of all services listed in the Dental Benefits Schedule for a period of four years; and
     (2)     Where a service in the Dental Benefits Schedule pertains to a particular tooth or teeth, the tooth or teeth must be recorded.
17            Limitation on number of certain services
              For any particular eligible dental patient, an item of the Dental Benefits Schedule mentioned in column 2 of the following table is applicable to a service not more than the number of times mentioned in column 3 of the table in the period mentioned in column 4 of the table.
 
Item
Item of service
Number of times
Period

1
88311, 88314, 88322, 88323, 88324
1
1 day

2
88111, 88114, 88121
1
6 months

3
88942
1
12 months

4
88221, 88721, 88722
1
24 months

5
88115, 88213
2
12 months

6
88013, 88572
3
3 months

7
88458
3
12 months

8
88022, 88161, 88575
4
1 day

9
88768
8
24 months

18            Limitation on provision of certain services
              For any particular eligible dental patient, an item of the Dental Benefits Schedule mentioned in column 2 of the following table is applicable to a service provided by a particular eligible dental provider, not more than once in the period mentioned in column 3 of the table.
 
Item
Item of service
Period

1
88012
6 months

2
88011
24 months

19            Limitation on Diagnostic Services
              For any particular eligible dental patient:
                (a)    an item listed in Subgroup 1 of Group U0 of the Dental Benefits Schedule:
                          (i)    is applicable to a service once only per day; and
                         (ii)    is not applicable to a service if the service is provided in combination with a service described in any of the other items in the Subgroup on that day that has been relevantly provided;
               (b)    item 88012 is not applicable to a service if the service is provided within 6 months of a service described in item 88011 being relevantly provided, where both services are provided by the same eligible dental provider.
20            Limitation on Preventive Services
              For any particular eligible dental patient:
                (a)    an item listed in Subgroup 1 of Group U1 of the Dental Benefits Schedule is not applicable to a service if:
                          (i)    the service is provided in combination with a service described in any of the other items in the Subgroup (the second service) on that day; and
                         (ii)    the second service is relevantly provided;
               (b)    an item listed in Subgroup 3 of Group U1 of the Dental Benefits Schedule is not applicable to a service if the service is provided in respect of the same tooth on the same day as a service described in any of the items 88511 to 88535 is relevantly provided.
21            Limitation on Periodontic Services
              For any particular eligible dental patient item 88213 is not applicable to a service if the service is provided in respect of a tooth on the same day as the service described in item 88415 is relevantly provided in respect of the same tooth.
22            Limitation on Oral Surgery
                        For any particular eligible dental patient:
                (a)    item 88311 is not applicable to a service if the service is provided on the same day as the service described in item 88314 is relevantly provided;
               (b)    item 88322 is not applicable to a service if the service is provided on the same day as a service described in either item 88323 or 88324 is relevantly provided;
                (c)    item 88323 is not applicable to a service if the service is provided on the same day as the service described in item 88324 is relevantly provided;
               (d)    item 88324 is applicable to a service provided in respect of a multi-rooted tooth only;
                (e)    for any tooth, only one of items 88311 to 88326 is applicable to a service provided in respect of that tooth;
                (f)    items 88384 to 88392 are not applicable to a service if the service is provided in respect of a tooth on any date after any of items 88311 to 88326 has been relevantly provided in respect of the same tooth;
               (g)    item 88351 is only applicable to a service if the service is provided on the same day as any of items 88384, 88386 or 88387 are relevantly provided.
23            Limitation on Endodontic Services
              For any particular eligible dental patient:
                (a)    item 88412 is applicable once only to a service provided in respect of a particular tooth;
               (b)    an item in Group U4 of the Dental Benefits Schedule is not applicable to a service if the service is provided in respect of a tooth at any time after item 88412 has been relevantly provided in respect of that same tooth;
                (c)    item 88415 is applicable once only to a service provided in respect of a particular tooth on a day;
               (d)    item 88416 is applicable to a service provided in respect of a particular tooth to a maximum of twice on a day;
                (e)    item 88417 is applicable once only to a service provided in respect of a particular tooth on a day;
                (f)    item 88418 is applicable to a service provided in respect of a particular tooth up to a maximum of twice on a day;
               (g)    item 88414 is not applicable to a service provided in respect of a tooth on the same day as the service described in item 88421 is relevantly provided in respect of that tooth;
               (h)    item 88418 is not applicable to a service provided in respect of a tooth on the same day as the service described in item 88419 is relevantly provided in respect of that tooth;
                (i)    item 88419 is not applicable to a service provided in respect of a tooth on the same day as any of items 88311 to 88326, 88411 to 88417, 88421, 88455, 88458 or 88511 to 88535 is relevantly provided in respect of that tooth;
                (j)    item 88421:
                          (i)    is applicable to a service once only per primary tooth; and
                         (ii)    is not applicable to a service if the service described in item 88414 is relevantly provided in respect of the same tooth on the same day;
               (k)    item 88458 may apply to a service provided on the same day as a service described in either item 88415 or 88416 is relevantly provided but no other item in Group U4 of the Dental Benefits Schedule, other than item 88455, will apply to a service until at least three months has elapsed.
24            Limitation on Restorative Services
                        For any particular eligible dental patient:
                (a)    only one of any of items 88511 to 88535 applies to a service provided in respect of a particular tooth on a day;
               (b)    item 88575:
                          (i)    only applies to a service provided in respect of a tooth if a service described in one of the items 88511 to 88535 has been relevantly provided in respect of that tooth on the same day; and
                         (ii)    may apply to a service provided in respect of a particular tooth up to a maximum of twice on a day;
                (c)    item 88597:
                          (i)    only applies to a service provided in respect of a particular tooth if a service described in one of the items 88511 to 88535 has been relevantly provided in respect of that tooth on the same day; and
                         (ii)    may apply to a service provided in respect of a particular tooth up to a maximum of twice on a day.
25            Limitation on Prosthodontics
              For any particular eligible dental patient:
                (a)    item 88731:
                          (i)    only applies to a service provided in respect of a denture base relevantly provided to the patient under item 88721 or 88722; and
                         (ii)    applies to a service a maximum of 4 times in respect of each denture base;
               (b)    item 88733:
                          (i)    only applies to a service provided in respect of a denture base relevantly provided to the patient under item 88721 or 88722; and
                         (ii)    applies to a service a maximum of 4 times in respect of each denture base; and
                        (iii)    applies to the fitting of an anterior tooth only;
                (c)    item 88736
                          (i)    only applies to a service provided in respect of a denture base relevantly provided to the patient under item 88721 or 88722; and
                         (ii)    applies to a service a maximum of 4 times in respect of each denture base;
               (d)    item 88741 does not apply to a service provided by a particular dental provider if the service is provided within a 12 month period of a service described in either item 88721 or 88722 being relevantly provided by the same dental provider.
26            Application of item 88455
                (a)    For any particular eligible dental patient, item 88455 does not apply to a service provided in respect of a tooth on a day if a service described in item 88414, 88415, 88416, 88417, 88418 or 88421 is relevantly provided in respect of the same tooth on the day.
               (b)    For any particular eligible dental patient, item 88455 applies to a service only if a service described in item 88415 or 88416 has been relevantly provided to the patient in the previous three months.
27            Limitation on items 88521 and 88531
                (a)    For any particular eligible dental patient, any combination of items 88521 and 88531 is applicable to not more than 5 services provided to the patient on a day.
               (b)    For the maximum of 5 services where it is possible to claim for item 88531 that item should be claimed.
28            Application of item 88572
              For any particular eligible dental patient, item 88572 does not apply to a service provided to the patient on a day if a service described in any of items 88411 to 88418 or items 88421 to 88458 is relevantly provided to the patient on the same day.
29            Application of item 88911
              For any particular eligible dental patient, item 88911 is not applicable to a service provided to the patient by a dental provider if another service in the Dental Benefits Schedule is relevantly provided to the patient by the same dental provider on the same day.
 
Schedule 1     Dental Benefits Schedule
(rule 5)
  
Item
Service
Benefit ($)

Group U0 – Diagnostic Services

Subgroup 1 – Examinations

88011
Comprehensive oral examination
Evaluation of all teeth, their supporting tissues and the oral tissues in order to record the condition of these structures. This evaluation includes recording an appropriate medical history and any other relevant information.
(Item is subject to Rules 18 and 19)
52.65

88012
Periodic oral examination
An evaluation performed on a patient of record to determine any changes in the patient’s dental and medical health status since a previous comprehensive or periodic examination.
(Item is subject to Rules 18 and 19)
43.75

88013
Oral examination – limited
A limited oral problem-focussed evaluation carried out immediately prior to required treatment. This evaluation includes recording an appropriate medical history and any other relevant information.
(Item is subject to Rules 17 and 19)
27.50

Subgroup 2 – Radiological examination and interpretation

88022
Intraoral periapical or bitewing radiograph – per exposure
Taking and interpreting a radiograph made with the film inside the mouth.
(Item is subject to Rule 17)
30.45

88025
Intraoral radiograph – occlusal, maxillary, mandibular – per exposure
Taking and interpreting an occlusal, maxillary or mandibular intraoral radiograph. This radiograph shows a more extensive view of teeth and maxillary or mandibular bone.
61.55

Group U1 – Preventive Services

Subgroup 1 – Dental Prophylaxis

88111
Removal of plaque and/or stain
Removal of dental plaque and/or stain from the surfaces of all teeth.
(Item is subject to Rules 17 and 20)
53.80

88114
Removal of calculus – first visit
Removal of calculus from the surfaces of teeth.
(Item is subject to Rules 17 and 20)
89.70

88115
Removal of calculus – subsequent visit
This item describes procedures in item 88114 when, because of the extent or degree of calculus, an additional visit(s) is required to remove deposits from the teeth.
(Item is subject to Rules 17 and 20)
58.35

Subgroup 2 – Remineralising Agents

88121
Topical application of remineralisation and/or cariostatic agents, one treatment
Application of remineralisation and/or cariostatic agents to the surfaces of the teeth. This may include activation of the agent. Not to be used as an intrinsic part of the restoration.
(Item is subject to Rule 17)
34.55

Subgroup 3 – Other Preventive Services

88161
Fissure and/or tooth surface sealing – per tooth (first four services on a day)
Sealing of non-carious pits, fissures, smooth surfaces or cracks in a tooth with an adhesive material. Any preparation prior to application of the sealant is included in this item number.
(Item is subject to Rule 17 and 20)
46.05

88162
Fissure and/or tooth surface sealing – per tooth (subsequent services)
Sealing of non-carious pits, fissures, smooth surfaces or cracks in a tooth with an adhesive material. Any preparation prior to application of the sealant is included in this item number.
(Item is subject to Rule 20)
23.05

Group U2 – Periodontics

88213
Treatment of acute periodontal infection – per visit
This item describes the treatment of acute periodontal infection(s). It may include establishing drainage and the removal of calculus from the affected tooth (teeth). Inclusive of the insertion of sutures, normal post-operative care and suture removal.
(Item is subject to Rules 17 and 21)
69.70

88221
Clinical periodontal analysis and recording
This is a special examination performed as part of the diagnosis and management of periodontal disease. The procedure consists of assessing and recording a patient's periodontal condition. All teeth and six sites per tooth must be recorded. Written documentation of these measurements must be retained.
(Item is subject to Rule 17)
52.95

Group U3 – Oral Surgery

Subgroup 1 – Extractions

88311
Removal of a tooth or part(s) thereof – first tooth extracted on a day
A procedure consisting of the removal of a tooth or part(s) thereof. Inclusive of the insertion of sutures, normal post-operative care and suture removal.
(Item is subject to Rules 17 and 22)
131.30

88314
Sectional removal of a tooth or part(s) thereof – first tooth extracted on a day
The removal of a tooth or part(s) thereof in sections. Bone removal may be necessary. Inclusive of the insertion of sutures, normal post-operative care and suture removal.
(Item is subject to Rules 17 and 22)
167.80

88316
Additional extraction requiring removal of a tooth or part(s) thereof, or sectional removal of a tooth.
Additional extraction provided on the same day as a service described in item 88311 or 88314 is provided to the patient.
(Item is subject to Rule 22)
82.75

Subgroup 2 – Surgical Extractions

88322
Surgical removal of a tooth or tooth fragment not requiring removal of bone or tooth division – first tooth extracted on a day
Removal of a tooth or tooth fragment where an incision and the raising of a mucoperiosteal flap is required, but where removal of bone or sectioning of the tooth is not necessary to remove the tooth. Inclusive of the insertion of sutures, normal post-operative care and suture removal.
(Item is subject to Rules 17 and 22)
213.10

88323
Surgical removal of a tooth or tooth fragment requiring removal of bone – first tooth extracted on a day
Removal of a tooth or tooth fragment where removal of bone is required after an incision and a mucoperiosteal flap raised. Inclusive of the insertion of sutures, normal post-operative care and suture removal.
(Item is subject to Rules 17 and 22)
243.35

88324
Surgical removal of a tooth or tooth fragment requiring both removal of bone and tooth division – first tooth extracted on a day
Removal of a tooth or tooth fragment where both removal of bone and sectioning of the tooth are required after an incision and a mucoperiosteal flap raised. The tooth will be removed in portions. Inclusive of the insertion of sutures, normal post-operative care and suture removal.
(Item is subject to Rules 17 and 22)
327.35

88326
Additional extraction requiring surgical removal of a tooth or tooth fragment
Additional surgical extraction provided on the same day as a service described in item 88322, 88323 or 88324 is provided to the patient.
(Item is subject to Rule 22)
174.35

Subgroup 5 – Treatment of Maxillo-facial injuries

88351
Repair of skin and subcutaneous tissue or mucous membrane
The surgical cleaning and repair of a facial skin wound in the region of the mouth or jaws, or the repair of oral mucous membrane, where the wounds involve the subcutaneous tissues. Inclusive of the insertion of sutures, normal post-operative care and suture removal.
(Item is subject to Rule 22)
159.95

Subgroup 8 – Other Surgical Procedures

88384
Repositioning of displaced tooth/teeth – per tooth
A procedure following trauma where the position of the displaced tooth/teeth is corrected by manipulation. Stabilising procedures are itemised separately. Inclusive of the insertion of sutures, normal post-operative care and suture removal.
(Item is subject to Rule 22)
190.85

88386
Splinting of displaced tooth/teeth – per tooth
A procedure following trauma where the position of the displaced tooth/teeth may be stabilized by splinting. Inclusive of the insertion of sutures, normal post-operative care and suture removal.
(Item is subject to Rule 22)
196.90

88387
Replantation and splinting of a tooth
Replantation of a tooth which has been avulsed or intentionally removed. It may be held in the correct position by splinting. Inclusive of the insertion of sutures, normal post-operative care and suture removal.
(Item is subject to Rule 22)
385.55

88392
Drainage of abscess
Drainage and/or irrigation of an abscess other than through a root canal or at the time of extraction. The drainage may be through an incision or inserted tube. Inclusive of the insertion of sutures, normal post-operative care and suture removal.
(Item is subject to Rule 22)
96.85

Group U4 – Endodontics

Subgroup 1 – Pulp and Root Canal Treatments

88411
Direct pulp capping
A procedure where an exposed pulp is directly covered with a protective dressing or cement.
34.85

88412
Incomplete endodontic therapy (tooth not suitable for further treatment)
A procedure where in assessing the suitability of a tooth for endodontic treatment a decision is made that the tooth is not suitable for restoration.
(Item is subject to Rule 23)
119.40

88414
Pulpotomy
Amputation within the pulp chamber of part of the vital pulp of a tooth. The pulp remaining in the canal(s) is then covered with a protective dressing or cement.
(Item is subject to Rule 23)
76.05

88415
Complete chemo-mechanical preparation of root canal – one canal
Complete chemo-mechanical preparation including removal of pulp or necrotic debris from a canal.
(Item is subject to Rule 23)
214.15

88416
Complete chemo-mechanical preparation of root canal – each additional canal
Complete chemo-mechanical preparation including removal of pulp or necrotic debris from each additional canal of a tooth with multiple canals.
(Item is subject to Rule 23)
102.00

88417
Root canal obturation – one canal
The filling of a root canal, following chemo-mechanical preparation.
(Item is subject to Rule 23)
208.60

88418
Root canal obturation – each additional canal
The filling, following chemo-mechanical preparation, of each additional canal in a tooth with multiple canals.
(Item is subject to Rule 23)
97.55

88419
Extirpation of pulp or debridement of root canal(s) – emergency or palliative
The partial or thorough removal of pulp and/or debris from the root canal system of a tooth. This is an emergency or palliative procedure distinct from visits for scheduled endodontic treatment.
(Item is subject to Rule 23)
137.90

88421
Resorbable root canal filling – primary tooth
The placement of resorbable root canal filling material in a primary tooth.
(Item is subject to Rule 23)
119.40

Subgroup 4 – Other Endodontic Services

88455
Additional visit for irrigation and/or dressing of the root canal system – per tooth
Additional debridement irrigation and short-term dressing required where evidence of infection or inflammation persists following prior opening of the root canal and removal of its contents.
(Item is subject to Rule 26)
105.70

88458
Interim therapeutic root filling – per tooth
A procedure consisting of the insertion of a long-term provisional (temporary) root canal filling with therapeutic properties which facilitates healing/development of the root and periradicular tissues over an extended time.
(Item is subject to Rules 17 and 23)
140.95

Group U5 – Restorative Services

Subgroup 1 – Metallic Restorations – Direct

88511
Metallic restoration – one surface – direct
Direct metallic restoration involving one surface of a tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post-operative care.
(Item is subject to Rule 24)
104.25

88512
Metallic restoration – two surfaces – direct
Direct metallic restoration involving two surfaces of a tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post-operative care.
(Item is subject to Rule 24)
127.80

88513
Metallic restoration – three surfaces – direct
Direct metallic restoration involving three surfaces of a tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post-operative care.
(Item is subject to Rule 24)
152.50

88514
Metallic restoration – four surfaces – direct
Direct metallic restoration involving four surfaces of a tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post-operative care.
(Item is subject to Rule 24)
173.85

88515
Metallic restoration – five surfaces – direct
Direct metallic restoration involving five surfaces of a tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post-operative care.
(Item is subject to Rule 24)
198.45

Subgroup 2 – Adhesive Restorations – Anterior Teeth – direct

88521
Adhesive restoration – one surface – anterior tooth – direct
Direct restoration, using an adhesive technique and a tooth-coloured material, involving one surface of an anterior tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post-operative care.
(Item is subject to Rules 24 and 27)
115.45

88522
Adhesive restoration – two surfaces – anterior tooth – direct
Direct restoration, using an adhesive technique and a tooth-coloured material, involving two surfaces of an anterior tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post-operative care.
(Item is subject to Rule 24)
140.15

88523
Adhesive restoration – three surfaces – anterior tooth – direct
Direct restoration, using an adhesive technique and a tooth-coloured material, involving three surfaces of an anterior tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post-operative care.
(Item is subject to Rule 24)
166.00

88524
Adhesive restoration – four surfaces – anterior tooth – direct
Direct restoration, using an adhesive technique and a tooth-coloured material, involving four surfaces of an anterior tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post-operative care.
(Item is subject to Rule 24)
191.85

88525
Adhesive restoration – five surfaces – anterior tooth – direct
Direct restoration, using an adhesive technique and a tooth-coloured material, involving five surfaces of an anterior tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post-operative care.
(Item is subject to Rule 24)
225.45

Subgroup 3 – Adhesive Restorations – Posterior Teeth – direct

88531
Adhesive restoration – one surface – posterior tooth – direct
Direct restoration, using an adhesive technique and a tooth-coloured material, involving one surface of an posterior tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post-operative care.
(Item is subject to Rules 24 and 27)
123.30

88532
Adhesive restoration – two surfaces – posterior tooth – direct
Direct restoration, using an adhesive technique and a tooth-coloured material, involving two surfaces of an posterior tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post-operative care.
(Item is subject to Rule 24)
154.80

88533
Adhesive restoration – three surfaces – posterior tooth – direct
Direct restoration, using an adhesive technique and a tooth-coloured material, involving three surfaces of an posterior tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post-operative care.
(Item is subject to Rule 24)
186.10

88534
Adhesive restoration – four surfaces – posterior tooth – direct
Direct restoration, using an adhesive technique and a tooth-coloured material, involving four surfaces of an posterior tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post-operative care.
(Item is subject to Rule 24)
209.70

88535
Adhesive restoration – five surfaces – posterior tooth – direct
Direct restoration, using an adhesive technique and a tooth-coloured material, involving five surfaces of an posterior tooth. Inclusive of the preparation of the tooth, placement of a lining, contouring of the adjacent and opposing teeth, placement of the restoration and normal post-operative care.
(Item is subject to Rule 24)
242.20

Subgroup 7 – Other Restorative Services

88572
Provisional (intermediate/temporary) restoration – per tooth
The provisional (intermediate) restoration of a tooth designed to last until the definitive restoration can be constructed or the tooth is removed. This item should only be used where the provisional (intermediate) restoration is not an intrinsic part of treatment. It does not include provisional (temporary) sealing of the access cavity during endodontic treatment or during construction of indirect restorations.
(Item is subject to Rules 17 and 28)
48.75

88574
Metal band
The cementation of a metal band for diagnostic, protective purposes or for the placement of a provisional (intermediate) restoration.
41.05

88575
Pin retention – per pin
Use of a pin to aid the retention and support of direct or indirect restorations in a tooth.
(Item is subject to Rules 17 and 24)
28.05

88576
Metallic crown – preformed
Placing a preformed metallic crown as a coronal restoration for a tooth.
257.05

88579
Bonding of tooth fragment
The direct bonding of a tooth fragment as an alternative to placing a restoration.
96.85

88597
Post – direct
Insertion of a post into a prepared root canal to provide an anchor for an artificial crown or other restoration.
(Item is subject to Rule 24)
88.15

Group U7 – Prosthodontics

Subgroup 1 – Dentures and Denture Components

88721
Partial maxillary denture – resin, base only
Provision of a resin base for a removable dental prosthesis for the maxilla where some natural teeth remain.
(Item is subject to Rule 17)
322.95

88722
Partial mandibular denture – resin, base only
Provision of a resin base for a removable dental prosthesis for the mandible where some natural teeth remain.
(Item is subject to Rule 17)
322.95

88731
Retainer – per tooth
A retainer or attachment fitted to a tooth to aid retention of a partial denture. The number of retainers should be indicated.
(Item is subject to Rule 25)
44.05

88733
Tooth/teeth (partial denture)
An item to describe each tooth added to the base of a new partial denture. The number of teeth should be indicated.
(Item is subject to Rule 25)
67.00

88736
Immediate tooth replacement – per tooth
Provision within a denture to allow immediate replacement of an extracted tooth. The number of teeth so replaced should be indicated.
(Item is subject to Rule 25)
9.10

Subgroup 4 – Denture Maintenance

88741
Adjustment of a denture
Adjustment of a denture to improve comfort, function or aesthetics. This item does not apply to routine adjustments following the insertion of a new denture or the maintenance or repair of an existing denture.
(Item is subject to Rule 25)
52.50

Subgroup 6 – Denture Repairs

88761
Reattaching pre-existing clasp to denture
Repair, insertion and adjustment of a denture involving re-attachment of a pre-existing clasp.
144.20

88762
Replacing/adding clasp to denture - per clasp
Repair, insertion and adjustment of a denture involving replacement or addition of a new clasp or clasps.
150.65

88764
Repairing broken base of a partial denture
Repair, insertion and adjustment of a broken resin partial denture base.
144.20

88765
Replacing/adding new tooth on denture – per tooth
Repair, insertion and adjustment of a denture involving replacement with or addition of a new tooth or teeth to a previously existing denture.
150.65

88766
Reattaching existing tooth on denture – per tooth
Repair, insertion and adjustment of a denture involving reattachment of a pre-existing denture tooth or teeth.
144.20

88768
Adding tooth to partial denture to replace an extracted or decoronated tooth - per tooth
Modification, insertion and adjustment of a partial denture involving an addition to accommodate the loss of a natural tooth or its coronal section.
(Item is subject to Rule 17)
152.50

Subgroup 7 – Other Prosthodontic Services

88776
Impression - dental appliance repair/modification
An item to describe taking an impression where required for the repair or modification of a dental appliance.
46.05

Group U9 – General Services

Subgroup 1– Emergencies

88911
Palliative care
An item to describe interim care to relieve pain, infection, bleeding or other problems not associated with other treatment.
(Item is subject to Rule 29)
68.35

Subgroup 4– Sedation

88942
Sedation - intravenous
Sedative drug(s) administered intravenously, usually in increments. The incremental administration may continue while dental treatment is being provided.
(Item is subject to rule 17)
134.00

88943
Sedation - inhalation
Nitrous oxide gas mixed with oxygen is inhaled by the patient while dental treatment is being provided.
67.00

 
Schedule 2     Eligibility of dental services rendered by or on behalf of or under an arrangement with a State or internal Territory
(rule 8A)
 

Column 1
State/ internal Territory
Column 2
Date service must be provided on or before:

Australian Capital Territory
30 June 2015

New South Wales
30 June 2015

Northern Territory
30 June 2015

Queensland
30 June 2015

South Australia
30 June 2015

Tasmania
30 June 2015

Victoria
30 June 2015

Western Australia
30 June 2015

Schedule 3     Benefit limits
(rule 14)
 
Relevant 2 year period
Cap

2014-2015
$1,000

2015-2016
$1,000