Health Insurance (Allied Health and Dental Services) Determination 2006
Health Insurance Act 1973
I, TONY ABBOTT, Minister for Health and Ageing, make this Determination under subsection 3C (1) of the Health Insurance Act 1973.
Dated 27 October 2006
TONY ABBOTT
Minister for Health and Ageing
1 Name of Determination
This Determination is the Health Insurance (Allied Health and Dental Services) Determination 2006.
2 Commencement
This Determination commences on 1 November 2006.
3 Revocation
The Health Insurance (Allied Health and Dental Services) Determination 2005 is revoked.
4 Interpretation
(1) In this Determination:
Act means the Health Insurance Act 1973.
allied health professional, in relation to the provision of an allied health service, means a person:
(a) who meets the qualification requirements set out in Schedule 1 for the provision of the service; and
(b) whose name is entered in the register, kept by Medicare Australia, of allied health professionals who are qualified to provide a service of that kind.
allied health service means a health service of a kind prescribed by regulation 3A of the Health Insurance Regulations 1975 that is specified in an item in Schedule 2.
dental assessment, in relation to a person, means a comprehensive assessment of the person’s dental health, and includes an evaluation of all teeth, their supporting structures and other oral tissues.
dental health service means a dental service that is specified in an item in Schedule 3.
eligible Aboriginal health worker means a person who is an allied health professional in relation to the provision of an Aboriginal or Torres Strait Islander health service.
eligible audiologist means a person who is an allied health professional in relation to the provision of an audiology health service.
eligible chiropractor means a person who is an allied health professional in relation to the provision of a chiropractic health service.
eligible clinical psychologist means a person who is an allied health professional in relation to the provision of a psychological therapy health service.
eligible dental practitioner means a dental practitioner whose name is entered in the register, kept by Medicare Australia, of dental practitioners who can provide services to which any of items 10975, 10976 and 10977 apply.
eligible dental specialist means a person:
(a) who is:
(i) registered or licensed as a periodontist, endodontist, pedeodontist, or orthodontist under a law of a State or Territory; or
(ii) registered or licensed as a dental specialist under a law of a State or Territory and recognised by the registering or licensing authority as a person who practises in the speciality of periodontics, endodontics, pedeodontics, or orthodontics; and
(b) whose name is entered in the register, kept by Medicare Australia, of dental specialists who can provide services to which item 10977 applies.
eligible diabetes educator means a person who is an allied health professional in relation to the provision of a diabetes education health service.
eligible dietitian means a person who is an allied health professional in relation to the provision of a dietetics health service.
eligible exercise physiologist means a person who is an eligible allied health professional in relation to the provision of an exercise physiology service.
eligible mental health nurse means a person who is an allied health professional in relation to the provision of a non‑directive pregnancy support counselling health service.
eligible mental health worker means a person who is an allied health professional in relation to the provision of a mental health service.
eligible occupational therapist means a person who is an allied health professional in relation to the provision of one or both of the following:
(a) a focussed psychological strategies health service;
(b) an occupational therapy health service.
eligible osteopath means a person who is an allied health professional in relation to the provision of an osteopathy health service.
eligible physiotherapist means a person who is an allied health professional in relation to the provision of a physiotherapy health service.
eligible podiatrist means a person who is an allied health professional in relation to the provision of a podiatry health service.
eligible psychologist means a person who is an allied health professional in relation to the provision of one or more of the following:
(a) a focussed psychological strategies health service;
(b) a non‑directive pregnancy support counselling health service;
(c) a psychology health service.
eligible social worker means a person who is an allied health professional in relation to the provision of one or both of the following:
(a) a focussed psychological strategies health service;
(b) a non‑directive pregnancy support counselling health service.
eligible speech pathologist means a person who is an allied health professional in relation to the provision of a speech pathology health service.
enhanced primary care multidisciplinary care plan, for a patient, means:
(a) a multidisciplinary care plan for the patient, to which item 731 of the general medical services table applies; or
(b) a multidisciplinary community care plan for the patient, to which item 720 of a repealed general medical services table applied; or
(c) a multidisciplinary discharge care plan for the patient, to which item 722 of a repealed general medical services table applied; or
(d) a multidisciplinary care plan for the patient, to which item 730 of a repealed general medical services table applied.
EPC plan, in relation to a patient, means:
(a) an enhanced primary care multidisciplinary care plan for the patient; or
(b) a care plan for the patient comprising:
(i) a GP management plan to which item 721 of the general medical services table applies; and
(ii) team care arrangements to which item 723 of the general medical services table applies.
focussed psychological strategies means any of the following mental health care management strategies, each of which has been derived from evidence‑based psychological therapies:
(a) psycho‑education;
(b) cognitive‑behavioural therapy that involves cognitive or behavioural interventions;
(c) relaxation strategies;
(d) skills training;
(e) interpersonal therapy.
GP Mental Health Care Plan, in relation to a patient, means a GP Mental Health Care Plan for the patient to which item 2710 of the general medical services table applies.
non‑directive pregnancy support counselling has the meaning given in subsection (2).
OT Australia means the national body of the Australian Association of Occupational Therapists.
repealed general medical services table means the table prescribed by any of the following Regulations:
(a) the Health Insurance (1999–2000 General Medical Services Table) Regulations 1999 as in force immediately before 1 November 2000;
(b) the Health Insurance (General Medical Services Table) Regulations 2000 as in force immediately before 1 November 2001;
(c) the Health Insurance (General Medical Services Table) Regulations 2001 as in force immediately before 1 November 2002;
(d) the Health Insurance (General Medical Services Table) Regulations 2002 as in force immediately before 1 November 2003;
(e) the Health Insurance (General Medical Services Table) Regulations 2003 as in force immediately before 1 November 2004;
(f) the Health Insurance (General Medical Services Table) Regulations 2004 as in force immediately before 1 November 2005.
Note The following terms are defined in subsection 3 (1) of the Act:
· dental practitioner
· general medical services table
· medical practitioner
· professional service.
(2) A reference in this Determination to non‑directive pregnancy support counselling is a reference to counselling provided to a woman by a health professional in which:
(a) information and issues relating to pregnancy are discussed; but
(b) the health professional does not impose his or her views or values about what the woman should or should not do in relation to the pregnancy.
5 Allied health services
An allied health service is, in the circumstances described in the item in Schedule 2 relating to the service, to be treated for the purposes of all provisions of the Act, the Regulations, the National Health Act 1953 and regulations under that Act relating to professional services or relating to medical services, as if:
(a) it were both a professional service and a medical service; and
(b) there were an item in the general medical services table that:
(i) related to the service; and
(ii) specified for the service a fee in relation to each State, being the fee specified in the item in Schedule 2 relating to the service.
6 Dental health services
A dental health service is, in the circumstances described in the item in Schedule 3 relating to the service, to be treated for the purposes of all provisions of the Act, the Regulations, the National Health Act 1953 and regulations under that Act, relating to professional services or relating to medical services, as if:
(a) it were both a professional service and a medical service; and
(b) there were an item in the general medical services table that:
(i) related to the service; and
(ii) specified for the service a fee in relation to each State, being the fee specified in the item in Schedule 3 relating to the service.
7 Maximum number of services for certain items
(1) This section applies to items 80000, 80005, 80010, 80015, 80100, 80105, 80110, 80115, 80125, 80130, 80135, 80140, 80150, 80155, 80160 and 80165.
(2) The maximum number of services that may be provided in a calendar year in relation to an item to which this section applies may be increased from 12 services to 18 services in exceptional circumstances.
(3) For subsection (2):
exceptional circumstances exist in relation to a service if the referring medical practitioner conducts a review and determines that it is appropriate and necessary in the circumstances to increase the maximum number of services.
8 Referrals by psychiatrists and paediatricians
(1) This section applies to items 80000 to 80020 and 80100 to 80170.
(2) The referral by a consultant physician specialising in the practice of his or her field of psychiatry must be a referral to which any of items 293 to 370 of the general medical services table applies.
(3) The referral by a consultant physician specialising in the practice of his or her field of paediatrics must be a referral to which any of items 104 to 131 of the general medical services table applies.
Schedule 1 Qualification requirements for allied health professionals
(section 4)
1.
Aboriginal or Torres Strait Islander health service
A person is an allied health professional in relation to the provision of an Aboriginal or Torres Strait Islander health service if:
(a) in the case of a person who provides an Aboriginal or Torres Strait Islander health service in a State or Territory other than the Northern Territory — the person has been awarded a Certificate Level III (or higher) in Aboriginal and Torres Strait Islander Health by a registered training organisation that meets training standards set by the Australian National Training Authority’s Australian Quality Training Framework;
(b) in the case of a person who provides an Aboriginal or Torres Strait Islander health service in the Northern Territory — the person is registered under the Health Practitioners Act 2004 (NT).
2.
Audiology health service
A person is an allied health professional in relation to the provision of an audiology health service if the person is:
(a) a Full Member of the Audiological Society of Australia and the holder of a Certificate of Clinical Practice issued by that Society; or
(b) an Ordinary Member — Audiologist, or a Fellow Audiologist, of the Australian College of Audiology.
3.
Chiropractic health service
A person is an allied health professional in relation to the provision of a chiropractic health service if the person is registered as a person who may provide that kind of service under the applicable law in force in the State or Territory in which the service is provided.
4.
Diabetes education health service
A person is an allied health professional in relation to the provision of a diabetes education health service if the person is credentialled by the Australian Diabetes Educators Association as a ‘Credentialled Diabetes Educator’.
5.
Dietetics health service
A person is an allied health professional in relation to the provision of a dietetics health service if the person is accredited by the Dietitians Association of Australia as an ‘Accredited Practising Dietitian’.
6.
Exercise physiology health service
A person is an allied health professional in relation to the provision of an exercise physiology health service if the person is accredited by the Australian Association for Exercise and Sports Science as an ‘Accredited Exercise Physiologist’.
7.
Focussed psychological strategies health service
A person is an allied health professional in relation to the provision of a focussed psychological strategies health service if the person meets one of the following requirements:
(a) the person is registered, without any limitation, with the Psychologists Registration Board established under the applicable law in force in the State or Territory in which the service is provided;
(b) the person is a member of the Australian Association of Social Workers (AASW) and certified by AASW as meeting the standards for mental health set out in the document published by AASW titled ‘Competency Standards for Mental Health Social Workers 1999’, as in force on 1 November 2006;
(c) the person:
(i) is a Full‑time Member, or a Part‑time Member, of OT Australia; and
(ii) is, in the case of a person who provides a focussed psychological strategies health service in Queensland, Western Australia, South Australia or the Northern Territory, registered as a person who may provide that kind of service under the applicable law in force in the State or Territory in which the service is provided; and
(iii) has a minimum of 2 years experience in mental health; and
(iv) has given an undertaking to OT Australia to observe the standards set out in the document published by OT Australia titled ‘The Australian Competency Standards for Occupational Therapists in Mental Health’, as in force on 1 November 2006.
8.
Mental health service
A person is an allied health professional in relation to the provision of a mental health service if the person meets one of the following requirements:
(a) the person meets the requirements specified for an allied health professional in relation to the provision of an Aboriginal or Torres Strait Islander health service;
(b) the person is:
(i) in the case of a person who provides a mental health service in Tasmania or the Australian Capital Territory — registered as a mental health nurse under a law of Tasmania or the Australian Capital Territory, as the case requires; and
(ii) in any other case — a credentialled mental health nurse, as certified by the Australian and New Zealand College of Mental Health Nurses;
(c) the person is:
(i) in the case of a person who provides a mental health service in New South Wales, Victoria, Tasmania or the Australian Capital Territory — a Full‑time Member, or a Part‑time Member, of OT Australia; and
(ii) in the case of a person who is an occupational therapist and provides a mental health service in Queensland, Western Australia, South Australia or the Northern Territory — registered as a person who may provide that kind of service under the applicable law in force in the State or Territory in which the service is provided;
(d) the person is registered, without any limitation, with the Psychologist Registration Board established under the applicable law in force in the State or Territory in which the service is provided;
(e) the person is:
(i) a Member of the Australian Association of Social Workers; and
(ii) certified by that Association as meeting the standards for mental health set out in the document published by that Association titled ‘Competency Standards for Mental Health Social Workers 1999’, as in force on 1 November 2006.
9.
Non‑directive pregnancy support counselling health service
A person is an allied health professional in relation to the provision of a non‑directive pregnancy support counselling health service if the person meets one of the following requirements:
(a) the person is certified by the Australian and New Zealand College of Mental Health Nurses:
(i) as a credentialled mental health nurse; and
(ii) as appropriately trained in non‑directive pregnancy counselling;
(b) the person is registered, without any limitation, with the Psychologists Registration Board established under the applicable law in force in the State or Territory in which the service is provided and certified by the Australian Psychological Society as appropriately trained in non‑directive pregnancy counselling;
(c) the person is:
(i) a member of the Australian Association of Social Workers (AASW); and
(ii) certified by AASW either as meeting the standards for mental health set out in the document published by that Association titled ‘Competency Standards for Mental Health Social Workers 1999’, as in force on 1 November 2006 or as an accredited social worker; and
(iii) certified by AASW as appropriately trained in non‑directive pregnancy counselling.
For this health service, a person is appropriately trained in non‑directive pregnancy counselling if the person has undergone training based on the key criteria contained in the document published by the Department titled ‘Key criteria for non‑directive pregnancy counselling training provided to GPs and allied health professionals in relation to the Medicare non‑directive pregnancy support counselling items’, as in force on 1 November 2006.
10.
Occupational therapy health service
A person is an allied health professional in relation to the provision of an occupational therapy health service if the person is:
(a) in the case of a person who provides an occupational therapy health service in New South Wales, Victoria, Tasmania or the Australian Capital Territory — a Full‑time Member, or a Part‑time Member, of OT Australia; and
(b) in the case of a person who provides an occupational therapy health service in Queensland, Western Australia, South Australia or the Northern Territory — registered as a person who may provide that kind of service under the applicable law in force in the State or Territory in which the service is provided.
11.
Osteopathy health service
A person is an allied health professional in relation to the provision of an osteopathy health service if the person is registered as a person who may provide that kind of service under the applicable law in force in the State or Territory in which the service is provided.
12.
Physiotherapy health service
A person is an allied health professional in relation to the provision of a physiotherapy health service if the person is registered as a person who may provide that kind of service under the applicable law in force in the State or Territory in which the service is provided.
13.
Podiatry health service
A person is an allied health professional in relation to the provision of a podiatry health service if the person is:
(a) in the case of a person who provides a podiatry health service in the Northern Territory:
(i) a Full Member of the Australian Podiatry Association in a State or Territory other than the Northern Territory; or
(ii) registered under a law of a State or Territory other than the Northern Territory to provide podiatry health services; and
(b) in the case of a person who provides a podiatry health service in a State or Territory other than the Northern Territory, registered as a person who may provide that kind of service under the applicable law in force in the State or Territory in which the service is provided.
14.
Psychological therapy health service
A person is an allied health professional in relation to the provision of a psychological therapy health service if the person is:
(a) registered, without any limitation, with the Psychologists Registration Board established under the applicable law in force in the State or Territory in which the service is provided; and
(b) a member of the Australian Psychological Society’s College of Clinical Psychologists or meets the requirements for such membership.
15.
Psychology health service
A person is an allied health professional in relation to the provision of a psychology health service if the person is registered, without any limitation, with the Psychologists Registration Board established under the applicable law in force in the State or Territory in which the service is provided.
16.
Speech pathology health service
A person is an allied health professional in relation to the provision of a speech pathology health service if the person is:
(a) in the case of a person who provides a speech pathology health service in a State or Territory other than Queensland — a Practising Member of Speech Pathology Australia; and
(b) in the case of a person who provides a speech pathology health service in Queensland — registered as a person who may provide that kind of service under the applicable law in force in Queensland.
Schedule 2 Allied health services
(section 5)
Part 1 Services and fees – general
Item
Service
Fee ($)
10950
Aboriginal or Torres Strait Islander health service provided to a person by an eligible Aboriginal health worker if:
(a) the service is provided to a person who has a chronic and complex condition that is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under an EPC plan; and
(b) the service is recommended in the person’s EPC plan as part of the management of the person’s chronic and complex condition; and
(c) the person is referred to the eligible Aboriginal health worker by the medical practitioner using a referral form that has been issued by the Department or a referral form that substantially complies with the form issued by the Department; and
(d) the person is not an admitted patient of a hospital or day‑hospital facility; and
(e) the service is provided to the person individually and in person; and
(f) the service is of at least 20 minutes duration; and
(g) after the service, the eligible Aboriginal health worker gives a written report to the referring medical practitioner mentioned in paragraph (c):
(i) if the service is the only service under the referral — in relation to that service; or
(ii) if the service is the first or last service under the referral — in relation to that service; or
(iii) if neither subparagraph (i) nor (ii) applies but the service involves matters that the referring medical practitioner would reasonably expect to be informed of — in relation to those matters; and
(h) for a service for which a private health insurance benefit is payable — the person who incurred the medical expenses for the service has elected to claim the medicare benefit for the service, and not the private health insurance benefit —
to a maximum of 5 services (including any services to which this item or any other item in Part 1 of this Schedule applies) in a calendar year
55.05
10951
Diabetes education health service provided to a person by an eligible diabetes educator if:
(a) the service is provided to a person who has a chronic and complex condition that is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under an EPC plan; and
(b) the service is recommended in the person’s EPC plan as part of the management of the person’s chronic and complex condition; and
(c) the person is referred to the eligible diabetes educator by the medical practitioner using a referral form that has been issued by the Department or a referral form that substantially complies with the form issued by the Department; and
(d) the person is not an admitted patient of a hospital or day‑hospital facility; and
(e) the service is provided to the person individually and in person; and
(f) the service is of at least 20 minutes duration; and
(g) after the service, the eligible diabetes educator gives a written report to the referring medical practitioner mentioned in paragraph (c):
(i) if the service is the only service under the referral — in relation to that service; or
(ii) if the service is the first or last service under the referral — in relation to that service; or
(iii) if neither subparagraph (i) nor (ii) applies but the service involves matters that the referring medical practitioner would reasonably expect to be informed of — in relation to those matters; and
(h) for a service for which a private health insurance benefit is payable — the person who incurred the medical expenses for the service has elected to claim the medicare benefit for the service, and not the private health insurance benefit —
to a maximum of 5 services (including any services to which this item or any other item in Part 1 of this Schedule applies) in a calendar year
55.05
10952
Audiology health service provided to a person by an eligible audiologist if:
(a) the service is provided to a person who has a chronic and complex condition that is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under an EPC plan; and
(b) the service is recommended in the person’s EPC plan as part of the management of the person’s chronic and complex condition; and
(c) the person is referred to the eligible audiologist by the medical practitioner using a referral form that has been issued by the Department or a referral form that substantially complies with the form issued by the Department; and
(d) the person is not an admitted patient of a hospital or day‑hospital facility; and
(e) the service is provided to the person individually and in person; and
(f) the service is of at least 20 minutes duration; and
(g) after the service, the eligible audiologist gives a written report to the referring medical practitioner mentioned in paragraph (c):
(i) if the service is the only service under the referral — in relation to that service; or
(ii) if the service is the first or last service under the referral — in relation to that service; or
(iii) if neither subparagraph (i) nor (ii) applies but the service involves matters that the referring medical practitioner would reasonably expect to be informed of — in relation to those matters; and
(h) for a service for which a private health insurance benefit is payable — the person who incurred the medical expenses for the service has elected to claim the medicare benefit for the service, and not the private health insurance benefit —
to a maximum of 5 services (including any services to which this item or any other item in Part 1 of this Schedule applies) in a calendar year
55.05
10953
Exercise physiology service provided to a person by an eligible exercise physiologist if:
(a) the service is provided to a person who has a chronic and complex condition that is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under an EPC plan; and
(b) the service is recommended in the person’s EPC plan as part of the management of the person’s chronic and complex condition; and
(c) the person is referred to the eligible exercise physiologist by the medical practitioner using a referral form that has been issued by the Department or a referral form that substantially complies with the form issued by the Department; and
(d) the person is not an admitted patient of a hospital or day‑hospital facility; and
(e) the service is provided to the person individually and in person; and
(f) the service is of at least 20 minutes duration; and
(g) after the service, the eligible exercise physiologist gives a written report to the referring medical practitioner mentioned in paragraph (c):
(i) if the service is the only service under the referral — in relation to that service; or
(ii) if the service is the first or last service under the referral — in relation to that service; or
(iii) if neither subparagraph (i) nor (ii) applies but the service involves matters that the referring medical practitioner would reasonably expect to be informed of — in relation to those matters; and
(h) for a service for which a private health insurance benefit is payable — the person who incurred the medical expenses for the service has elected to claim the medicare benefit for the service, and not the private health insurance benefit —
to a maximum of 5 services (including any services to which this item or any other item in Part 1 of this Schedule applies) in a calendar year
55.05
10954
Dietetics health service provided to a person by an eligible dietitian if:
(a) the service is provided to a person who has a chronic and complex condition that is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under an EPC plan; and
(b) the service is recommended in the person’s EPC plan as part of the management of the person’s chronic and complex condition; and
(c) the person is referred to the eligible dietitian by the medical practitioner using a referral form that has been issued by the Department or a referral form that substantially complies with the form issued by the Department; and
(d) the person is not an admitted patient of a hospital or day‑hospital facility; and
(e) the service is provided to the person individually and in person; and
(f) the service is of at least 20 minutes duration; and
(g) after the service, the eligible dietitian gives a written report to the referring medical practitioner mentioned in paragraph (c):
(i) if the service is the only service under the referral — in relation to that service; or
(ii) if the service is the first or last service under the referral — in relation to that service; or
(iii) if neither subparagraph (i) nor (ii) applies but the service involves matters that the referring medical practitioner would reasonably expect to be informed of — in relation to those matters; and
(h) for a service for which a private health insurance benefit is payable — the person who incurred the medical expenses for the service has elected to claim the medicare benefit for the service, and not the private health insurance benefit —
to a maximum of 5 services (including any services to which this item or any other item in Part 1 of this Schedule applies) in a calendar year
55.05
10956
Mental health service provided to a person by an eligible mental health worker if:
(a) the service is provided to a person who has a chronic and complex condition that is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under an EPC plan; and
(b) the service is recommended in the person’s EPC plan as part of the management of the person’s chronic and complex condition; and
(c) the person is referred to the eligible mental health worker by the medical practitioner using a referral form that has been issued by the Department or a referral form that substantially complies with the form issued by the Department; and
(d) the person is not an admitted patient of a hospital or day‑hospital facility; and
(e) the service is provided to the person individually and in person; and
(f) the service is of at least 20 minutes duration; and
(g) after the service, the eligible mental health worker gives a written report to the referring medical practitioner mentioned in paragraph (c):
(i) if the service is the only service under the referral — in relation to that service; or
(ii) if the service is the first or last service under the referral — in relation to that service; or
(iii) if neither subparagraph (i) nor (ii) applies but the service involves matters that the referring medical practitioner would reasonably expect to be informed of — in relation to those matters; and
(h) for a service for which a private health insurance benefit is payable — the person who incurred the medical expenses for the service has elected to claim the medicare benefit for the service, and not the private health insurance benefit —
to a maximum of 5 services (including any services to which this item or any other item in Part 1 of this Schedule applies) in a calendar year
55.05
10958
Occupational therapy health service provided to a person by an eligible occupational therapist if:
(a) the service is provided to a person who has a chronic and complex condition that is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under an EPC plan; and
(b) the service is recommended in the person’s EPC plan as part of the management of the person’s chronic and complex condition; and
(c) the person is referred to the eligible occupational therapist by the medical practitioner using a referral form that has been issued by the Department or a referral form that substantially complies with the form issued by the Department; and
(d) the person is not an admitted patient of a hospital or day‑hospital facility; and
(e) the service is provided to the person individually and in person; and
(f) the service is of at least 20 minutes duration; and
(g) after the service, the eligible occupational therapist gives a written report to the referring medical practitioner mentioned in paragraph (c):
(i) if the service is the only service under the referral — in relation to that service; or
(ii) if the service is the first or last service under the referral — in relation to that service; or
(iii) if neither subparagraph (i) nor (ii) applies but the service involves matters that the referring medical practitioner would reasonably expect to be informed of — in relation to those matters; and
(h) for a service for which a private health insurance benefit is payable — the person who incurred the medical expenses for the service has elected to claim the medicare benefit for the service, and not the private health insurance benefit —
to a maximum of 5 services (including any services to which this item or any other item in Part 1 of this Schedule applies) in a calendar year
55.05
10960
Physiotherapy health service provided to a person by an eligible physiotherapist if:
(a) the service is provided to a person who has a chronic and complex condition that is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under an EPC plan; and
(b) the service is recommended in the person’s EPC plan as part of the management of the person’s chronic and complex condition; and
(c) the person is referred to the eligible physiotherapist by the medical practitioner using a referral form that has been issued by the Department or a referral form that substantially complies with the form issued by the Department; and
(d) the person is not an admitted patient of a hospital or day‑hospital facility; and
(e) the service is provided to the person individually and in person; and
(f) the service is of at least 20 minutes duration; and
(g) after the service, the eligible physiotherapist gives a written report to the referring medical practitioner mentioned in paragraph (c):
(i) if the service is the only service under the referral — in relation to that service; or
(ii) if the service is the first or last service under the referral — in relation to that service; or
(iii) if neither subparagraph (i) nor (ii) applies but the service involves matters that the referring medical practitioner would reasonably expect to be informed of — in relation to those matters; and
(h) for a service for which a private health insurance benefit is payable — the person who incurred the medical expenses for the service has elected to claim the medicare benefit for the service, and not the private health insurance benefit —
to a maximum of 5 services (including any services to which this item or any other item in Part 1 of this Schedule applies) in a calendar year
55.05
10962
Podiatry health service provided to a person by an eligible podiatrist, if:
(a) the service is provided to a person who has a chronic and complex condition that is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under an EPC plan; and
(b) the service is recommended in the person’s EPC plan as part of the management of the person’s chronic and complex condition; and
(c) the person is referred to the eligible podiatrist by the medical practitioner using a referral form that has been issued by the Department or a referral form that substantially complies with the form issued by the Department; and
(d) the person is not an admitted patient of a hospital or day‑hospital facility; and
(e) the service is provided to the person individually and in person; and
(f) the service is of at least 20 minutes duration; and
(g) after the service, the eligible podiatrist gives a written report to the referring medical practitioner mentioned in paragraph (c):
(i) if the service is the only service under the referral — in relation to that service; or
(ii) if the service is the first or last service under the referral — in relation to that service; or
(iii) if neither subparagraph (i) nor (ii) applies but the service involves matters that the referring medical practitioner would reasonably expect to be informed of — in relation to those matters; and
(h) for a service for which a private health insurance benefit is payable — the person who incurred the medical expenses for the service has elected to claim the medicare benefit for the service, and not the private health insurance benefit —
to a maximum of 5 services (including any services to which this item or any other item in Part 1 of this Schedule applies) in a calendar year
55.05
10964
Chiropractic health service provided to a person by an eligible chiropractor if:
(a) the service is provided to a person who has a chronic and complex condition that is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under an EPC plan; and
(b) the service is recommended in the person’s EPC plan as part of the management of the person’s chronic and complex condition; and
(c) the person is referred to the eligible chiropractor by the medical practitioner using a referral form that has been issued by the Department or a referral form that substantially complies with the form issued by the Department; and
(d) the person is not an admitted patient of a hospital or day‑hospital facility; and
(e) the service is provided to the person individually and in person; and
(f) the service is of at least 20 minutes duration; and
(g) after the service, the eligible chiropractor gives a written report to the referring medical practitioner mentioned in paragraph (c):
(i) if the service is the only service under the referral — in relation to that service; or
(ii) if the service is the first or last service under the referral — in relation to that service; or
(iii) if neither subparagraph (i) nor (ii) applies but the service involves matters that the referring medical practitioner would reasonably expect to be informed of — in relation to those matters; and
(h) for a service for which a private health insurance benefit is payable — the person who incurred the medical expenses for the service has elected to claim the medicare benefit for the service, and not the private health insurance benefit —
to a maximum of 5 services (including any services to which this item or any other item in Part 1 of this Schedule applies) in a calendar year
55.05
10966
Osteopathy health service provided to a person by an eligible osteopath if:
(a) the service is provided to a person who has a chronic and complex condition that is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under an EPC plan; and
(b) the service is recommended in the person’s EPC plan as part of the management of the person’s chronic and complex condition; and
(c) the person is referred to the eligible osteopath by the medical practitioner using a referral form that has been issued by the Department or a referral form that substantially complies with the form issued by the Department; and
(d) the person is not an admitted patient of a hospital or day‑hospital facility; and
(e) the service is provided to the person individually and in person; and
(f) the service is of at least 20 minutes duration; and
(g) after the service, the eligible osteopath gives a written report to the referring medical practitioner mentioned in paragraph (c):
(i) if the service is the only service under the referral — in relation to that service; or
(ii) if the service is the first or last service under the referral — in relation to that service; or
(iii) if neither subparagraph (i) nor (ii) applies but the service involves matters that the referring medical practitioner would reasonably expect to be informed of — in relation to those matters; and
(h) for a service for which a private health insurance benefit is payable — the person who incurred the medical expenses for the service has elected to claim the medicare benefit for the service, and not the private health insurance benefit —
to a maximum of 5 services (including any services to which this item or any other item in Part 1 of this Schedule applies) in a calendar year
55.05
10968
Psychology health service provided to a person by an eligible psychologist if:
(a) the service is provided to a person who has a chronic and complex condition that is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under an EPC plan; and
(b) the service is recommended in the person’s EPC plan as part of the management of the person’s chronic and complex condition; and
(c) the person is referred to the eligible psychologist by the medical practitioner using a referral form that has been issued by the Department or a referral form that substantially complies with the form issued by the Department; and
(d) the person is not an admitted patient of a hospital or day‑hospital facility; and
(e) the service is provided to the person individually and in person; and
(f) the service is of at least 20 minutes duration; and
(g) after the service, the eligible psychologist gives a written report to the referring medical practitioner mentioned in paragraph (c):
(i) if the service is the only service under the referral — in relation to that service; or
(ii) if the service is the first or last service under the referral — in relation to that service; or
(iii) if neither subparagraph (i) nor (ii) applies but the service involves matters that the referring medical practitioner would reasonably expect to be informed of — in relation to those matters; and
(h) for a service for which a private health insurance benefit is payable — the person who incurred the medical expenses for the service has elected to claim the medicare benefit for the service, and not the private health insurance benefit —
to a maximum of 5 services (including any services to which this item or any other item in Part 1 of this Schedule applies) in a calendar year
55.05
10970
Speech pathology health service provided to a person by an eligible speech pathologist if:
(a) the service is provided to a person who has a chronic and complex condition that is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under an EPC plan; and
(b) the service is recommended in the person’s EPC plan as part of the management of the person’s chronic and complex condition; and
(c) the person is referred to the eligible speech pathologist by the medical practitioner using a referral form that has been issued by the Department or a referral form that substantially complies with the form issued by the Department; and
(d) the person is not an admitted patient of a hospital or day‑hospital facility; and
(e) the service is provided to the person individually and in person; and
(f) the service is of at least 20 minutes duration; and
(g) after the service, the eligible speech pathologist gives a written report to the referring medical practitioner mentioned in paragraph (c):
(i) if the service is the only service under the referral — in relation to that service; or
(ii) if the service is the first or last service under the referral — in relation to that service; or
(iii) if neither subparagraph (i) nor (ii) applies but the service involves matters that the referring medical practitioner would reasonably expect to be informed of — in relation to those matters; and
(h) for a service for which a private health insurance benefit is payable — the person who incurred the medical expenses for the service has elected to claim the medicare benefit for the service, and not the private health insurance benefit —
to a maximum of 5 services (including any services to which this item or any other item in Part 1 of this Schedule applies) in a calendar year
55.05
Part 2 Services and fees – psychological therapy and focussed psychological strategies
Item
Service
Fee ($)
80000
Psychological therapy health service provided to a person in consulting rooms (but not as an admitted patient of a hospital or day‑hospital facility) by an eligible clinical psychologist if:
(a) the person is referred by:
(i) a medical practitioner, either as part of a GP Mental Health Care Plan or as part of a psychiatrist assessment and management plan; or
(ii) a consultant physician specialising in the practice of his or her field of psychiatry; or
(iii) a consultant physician specialising in the practice of his or her field of paediatrics; and
(b) before the provision of the 7th service in a course of treatment, the referring medical practitioner conducts a review and determines services in excess of 6 are needed; and
(c) on the completion of the course of treatment, the eligible clinical psychologist gives a written report to the referring medical practitioner on assessments carried out, treatment provided and recommendations on future management of the person’s condition; and
(d) the service is at least 30 minutes but less than 50 minutes duration —
to a maximum of 12 services (including services to which items 2721 to 2727, 80000 to 80015, 80100 to 80115, 80125 to 80140, 80150 to 80165, and the Access to Allied Psychological Services component of the Better Outcomes in Mental Health Care Program apply) in a calendar year
This item is subject to sections 7 and 8
88.20
80005
Psychological therapy health service provided to a person at a place other than consulting rooms (but not as an admitted patient of a hospital or day‑hospital facility) by an eligible clinical psychologist in accordance with the requirements of item 80000
This item is subject to sections 7 and 8
110.20
80010
Psychological therapy health service provided to a person in consulting rooms (but not as an admitted patient of a hospital or day‑hospital facility) by an eligible clinical psychologist if:
(a) the person is referred by:
(i) a medical practitioner, either as part of a GP Mental Health Care Plan or as part of a psychiatrist assessment and management plan; or
(ii) a consultant physician specialising in the practice of his or her field of psychiatry; or
(iii) a consultant physician specialising in the practice of his or her field of paediatrics; and
(b) before the provision of the 7th service in a course of treatment, the referring medical practitioner conducts a review and determines services in excess of 6 are needed; and
(c) on the completion of the course of treatment, the eligible clinical psychologist gives a written report to the referring medical practitioner on assessments carried out, treatment provided and recommendations on future management of the person’s condition; and
(d) the service is at least 50 minutes duration —
to a maximum of 12 services (including services to which items 2721 to 2727, 80000 to 80015, 80100 to 80115, 80125 to 80140, 80150 to 80165, and the Access to Allied Psychological Services component of the Better Outcomes in Mental Health Care Program apply) in a calendar year
This item is subject to sections 7 and 8
129.40
80015
Psychological therapy health service provided to a person at a place other than consulting rooms (but not as an admitted patient of a hospital or day‑hospital facility) by an eligible clinical psychologist in accordance with the requirements of item 80010
This item is subject to sections 7 and 8
151.40
80020
Psychological therapy health service provided to a person as part of a group of 6 to 10 patients (but not as an admitted patient of a hospital or day‑hospital facility) by an eligible clinical psychologist if:
(a) the person is referred by:
(i) a medical practitioner, either as part of a GP Mental Health Care Plan or as part of a psychiatrist assessment and management plan; or
(ii) a consultant physician specialising in the practice of his or her field of psychiatry; or
(iii) a consultant physician specialising in the practice of his or her field of paediatrics; and
(b) the service is at least 60 minutes duration —
to a maximum of 12 services (including services to which items 80120, 80145 and 80170 apply) in a calendar year
This item is subject to section 8
32.90
80100
Focussed psychological strategies health service provided to a person in consulting rooms (but not as an admitted patient of a hospital or day‑hospital facility) by an eligible psychologist if:
(a) the person is referred by:
(i) a medical practitioner, either as part of a GP Mental Health Care Plan or as part of a psychiatrist assessment and management plan; or
(ii) a consultant physician specialising in the practice of his or her field of psychiatry; or
(iii) a consultant physician specialising in the practice of his or her field of paediatrics; and
(b) before the provision of the 7th service in a course of treatment, the referring medical practitioner conducts a review and determines services in excess of 6 are needed; and
(c) on the completion of the course of treatment, the eligible psychologist gives a written report to the referring medical practitioner on assessments carried out, treatment provided and recommendations on future management of the person’s condition; and
(d) the service is at least 20 minutes but less than 50 minutes duration —
to a maximum of 12 services (including services to which items 2721 to 2727, 80000 to 80015, 80100 to 80115, 80125 to 80140, 80150 to 80165, and the Access to Allied Psychological Services component of the Better Outcomes in Mental Health Care Program apply) in a calendar year
This item is subject to sections 7 and 8
62.50
80105
Focussed psychological strategies health service provided to a person at a place other than consulting rooms (but not as an admitted patient of a hospital or day‑hospital facility) by an eligible psychologist in accordance with the requirements of item 80100
This item is subject to sections 7 and 8
84.95
80110
Focussed psychological strategies health service provided to a person in consulting rooms (but not as an admitted patient of a hospital or day‑hospital facility) by an eligible psychologist if:
(a) the person is referred by:
(i) a medical practitioner, either as part of a GP Mental Health Care Plan or as part of a psychiatrist assessment and management plan; or
(ii) a consultant physician specialising in the practice of his or her field of psychiatry; or
(iii) a consultant physician specialising in the practice of his or her field of paediatrics; and
(b) before the provision of the 7th service in a course of treatment, the referring medical practitioner conducts a review and determines services in excess of 6 are needed; and
(c) on the completion of the course of treatment, the eligible psychologist gives a written report to the referring medical practitioner on assessments carried out, treatment provided and recommendations on future management of the person’s condition; and
(d) the service is at least 50 minutes duration —
to a maximum of 12 services (including services to which items 2721 to 2727, 80000 to 80015, 80100 to 80115, 80125 to 80140, 80150 to 80165, and the Access to Allied Psychological Services component of the Better Outcomes in Mental Health Care Program apply) in a calendar year
This item is subject to sections 7 and 8
88.20
80115
Focussed psychological strategies health service provided to a person at a place other than consulting rooms (but not as an admitted patient of a hospital or day‑hospital facility) by an eligible psychologist in accordance with the requirements of item 80110
This item is subject to sections 7 and 8
110.70
80120
Focussed psychological strategies health service provided to a person as part of a group of 6 to 10 patients (but not as an admitted patient of a hospital or day‑hospital facility) by an eligible psychologist if:
(a) the person is referred by:
(i) a medical practitioner, either as part of a GP Mental Health Care Plan or as part of a psychiatrist assessment and management plan; or
(ii) a consultant physician specialising in the practice of his or her field of psychiatry; or
(iii) a consultant physician specialising in the practice of his or her field of paediatrics; and
(b) the service is at least 60 minutes duration —
to a maximum of 12 services (including services to which items 80120, 80145 and 80170 apply) in a calendar year
This item is subject to section 8
22.45
80125
Focussed psychological strategies health service provided to a person in consulting rooms (but not as an admitted patient of a hospital or day‑hospital facility) by an eligible occupational therapist if:
(a) the person is referred by:
(i) a medical practitioner, either as part of a GP Mental Health Care Plan or as part of a psychiatrist assessment and management plan; or
(ii) a consultant physician specialising in the practice of his or her field of psychiatry; or
(iii) a consultant physician specialising in the practice of his or her field of paediatrics; and
(b) before the provision of the 7th service in a course of treatment, the referring medical practitioner conducts a review and determines services in excess of 6 are needed; and
(c) on the completion of the course of treatment, the eligible occupational therapist gives a written report to the referring medical practitioner on assessments carried out, treatment provided and recommendations on future management of the person’s condition; and
(d) the service is at least 20 minutes but less than 50 minutes duration —
to a maximum of 12 services (including services to which items 2721 to 2727, 80000 to 80015, 80100 to 80115, 80125 to 80140, 80150 to 80165, and the Access to Allied Psychological Services component of the Better Outcomes in Mental Health Care Program apply) in a calendar year
This item is subject to sections 7 and 8
55.05
80130
Focussed psychological strategies health service provided to a person at a place other than consulting rooms (but not as an admitted patient of a hospital or day‑hospital facility) by an eligible occupational therapist in accordance with the requirements of item 80125
This item is subject to sections 7 and 8
77.50
80135
Focussed psychological strategies health service provided to a person in consulting rooms (but not as an admitted patient of a hospital or day‑hospital facility) by an eligible occupational therapist if:
(a) the person is referred by:
(i) a medical practitioner, either as part of a GP Mental Health Care Plan or as part of a psychiatrist assessment and management plan; or
(ii) a consultant physician specialising in the practice of his or her field of psychiatry; or
(iii) a consultant physician specialising in the practice of his or her field of paediatrics; and
(b) before the provision of the 7th service in a course of treatment, the referring medical practitioner conducts a review and determines services in excess of 6 are needed; and
(c) on the completion of the course of treatment, the eligible occupational therapist gives a written report to the referring medical practitioner on assessments carried out, treatment provided and recommendations on future management of the person’s condition; and
(d) the service is at least 50 minutes duration —
to a maximum of 12 services (including services to which items 2721 to 2727, 80000 to 80015, 80100 to 80115, 80125 to 80140, 80150 to 80165, and the Access to Allied Psychological Services component of the Better Outcomes in Mental Health Care Program apply) in a calendar year
This item is subject to sections 7 and 8
77.70
80140
Focussed psychological strategies health service provided to a person at a place other than consulting rooms (but not as an admitted patient of a hospital or day‑hospital facility) by an eligible occupational therapist in accordance with the requirements of item 80135
This item is subject to sections 7 and 8
100.15
80145
Focussed psychological strategies health service provided to a person as part of a group of 6 to 10 patients (but not as an admitted patient of a hospital or day‑hospital facility) by an eligible occupational therapist if:
(a) the person is referred by:
(i) a medical practitioner, either as part of a GP Mental Health Care Plan or as part of a psychiatrist assessment and management plan; or
(ii) a consultant physician specialising in the practice of his or her field of psychiatry; or
(iii) a consultant physician specialising in the practice of his or her field of paediatrics; and
(b) the service is at least 60 minutes duration —
to a maximum of 12 services (including services to which items 80120, 80145 and 80170 apply) in a calendar year
This item is subject to section 8
19.75
80150
Focussed psychological strategies health service provided to a person in consulting rooms (but not as an admitted patient of a hospital or day‑hospital facility) by an eligible social worker if:
(a) the person is referred by:
(i) a medical practitioner, either as part of a GP Mental Health Care Plan or as part of a psychiatrist assessment and management plan; or
(ii) a consultant physician specialising in the practice of his or her field of psychiatry; or
(iii) a consultant physician specialising in the practice of his or her field of paediatrics; and
(b) before the provision of the 7th service in a course of treatment, the referring medical practitioner conducts a review and determines services in excess of 6 are needed; and
(c) on the completion of the course of treatment, the eligible social worker gives a written report to the referring medical practitioner on assessments carried out, treatment provided and recommendations on future management of the person’s condition; and
(d) the service is at least 20 minutes but less than 50 minutes duration —
to a maximum of 12 services (including services to which items 2721 to 2727, 80000 to 80015, 80100 to 80115, 80125 to 80140, 80150 to 80165, and the Access to Allied Psychological Services component of the Better Outcomes in Mental Health Care Program apply) in a calendar year
This item is subject to sections 7 and 8
55.05
80155
Focussed psychological strategies health service provided to a person at a place other than consulting rooms (but not as an admitted patient of a hospital or day‑hospital facility) by an eligible social worker in accordance with the requirements of item 80150
This item is subject to sections 7 and 8
77.50
80160
Focussed psychological strategies health service provided to a person in consulting rooms (but not as an admitted patient of a hospital or day‑hospital facility) by an eligible social worker if:
(a) the person is referred by:
(i) a medical practitioner, either as part of a GP Mental Health Care Plan or as part of a psychiatrist assessment and management plan; or
(ii) a consultant physician specialising in the practice of his or her field of psychiatry; or
(iii) a consultant physician specialising in the practice of his or her field of paediatrics; and
(b) before the provision of the 7th service in a course of treatment, the referring medical practitioner conducts a review and determines services in excess of 6 are needed; and
(c) on the completion of the course of treatment, the eligible social worker gives a written report to the referring medical practitioner on assessments carried out, treatment provided and recommendations on future management of the person’s condition; and
(d) the service is at least 50 minutes duration —
to a maximum of 12 services (including services to which items 2721 to 2727, 80000 to 80015, 80100 to 80115, 80125 to 80140, 80150 to 80165, and the Access to Allied Psychological Services component of the Better Outcomes in Mental Health Care Program apply) in a calendar year
This item is subject to sections 7 and 8
77.70
80165
Focussed psychological strategies health service provided to a person at a place other than consulting rooms (but not as an admitted patient of a hospital or day‑hospital facility) by an eligible social worker in accordance with the requirements of item 80160
This item is subject to sections 7 and 8
100.15
80170
Focussed psychological strategies health service provided to a person as part of a group of 6 to 10 patients (but not as an admitted patient of a hospital or day‑hospital facility) by an eligible social worker if:
(a) the person is referred by:
(i) a medical practitioner, either as part of a GP Mental Health Care Plan or as part of a psychiatrist assessment and management plan; or
(ii) a consultant physician specialising in the practice of his or her field of psychiatry; or
(iii) a consultant physician specialising in the practice of his or her field of paediatrics; and
(b) the service is at least 60 minutes duration —
to a maximum of 12 services (including services to which items 80120, 80145 and 80170 apply) in a calendar year
This item is subject to section 8
19.75
Part 3 Services and fees – pregnancy support counselling
Item
Service
Fee ($)
81000
Non‑directive pregnancy support counselling health service provided to a woman (but not as an admitted patient of a hospital or day‑hospital facility) by an eligible psychologist if:
(a) the woman is concerned about a current pregnancy or a pregnancy that occurred in the 12 months preceding the provision of the first service; and
(b) the woman is referred by a medical practitioner who is not a specialist or consultant physician; and
(c) the eligible psychologist does not have a direct pecuniary interest in a health service that has as its primary purpose the provision of services for pregnancy termination; and
(d) the service is at least 30 minutes duration —
to a maximum of 3 services (including services to which items 81000, 81005, 81010 and 4001* apply) for each pregnancy
The service may be used to address any pregnancy related issues for which non‑directive counselling is appropriate
[* in the general medical services table]
64.70
81005
Non‑directive pregnancy support counselling health service provided to a woman (but not as an admitted patient of a hospital or day‑hospital facility) by an eligible social worker if:
(a) the woman is concerned about a current pregnancy or a pregnancy that occurred in the 12 months preceding the provision of the first service; and
(b) the woman is referred by a medical practitioner who is not a specialist or consultant physician; and
(c) the eligible social worker does not have a direct pecuniary interest in a health service that has as its primary purpose the provision of services for pregnancy termination; and
(d) the service is at least 30 minutes duration —
to a maximum of 3 services (including services to which items 81000, 81005, 81010 and 4001* apply) for each pregnancy
The service may be used to address any pregnancy related issues for which non‑directive counselling is appropriate
[* in the general medical services table]
64.70
81010
Non‑directive pregnancy support counselling health service provided to a woman (but not as an admitted patient of a hospital or day‑hospital facility) by an eligible mental health nurse if:
(a) the woman is concerned about a current pregnancy or a pregnancy that occurred in the 12 months preceding the provision of the first service; and
(b) the woman is referred by a medical practitioner who is not a specialist or consultant physician; and
(c) the eligible mental health nurse does not have a direct pecuniary interest in a health service that has as its primary purpose the provision of services for pregnancy termination; and
(d) the service is at least 30 minutes duration —
to a maximum of 3 services (including services to which items 81000, 81005, 81010 and 4001* apply) for each pregnancy
The service may be used to address any pregnancy related issues for which non‑directive counselling is appropriate
[* in the general medical services table]
64.70
Schedule 3 Dental health services
(section 6)
Services and fees
Item
Service
Fee ($)
10975
Dental assessment provided to a person by an eligible dental practitioner if:
(a) the service is provided to a person whose dental condition is exacerbating a chronic and complex condition that is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under an EPC plan; and
(b) the service is recommended in the person’s EPC plan as part of the management of the person’s chronic and complex condition; and
(c) the person is referred to the eligible dental practitioner by the medical practitioner using a referral form that has been issued by the Department or a referral form that substantially complies with the form issued by the Department; and
(d) the person is not an admitted patient of a hospital or day‑hospital facility; and
(e) after the assessment, the eligible dental practitioner gives a written report to the referring medical practitioner; and
(f) for a service for which a private health insurance benefit is payable — the person who incurred the medical expenses for the service has elected to claim the medicare benefit for the service, and not the private health insurance benefit —
to a maximum of 3 services (including any services to which this item or item 10976 or 10977 applies) in a calendar year
91.70
10976
Dental treatment provided to a person by an eligible dental practitioner if:
(a) the service is provided to a person whose dental condition is exacerbating a chronic and complex condition that is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under an EPC plan; and
(b) the service is recommended in the person’s EPC plan as part of the management of the person’s chronic and complex condition; and
(c) the service is associated with a service of the kind described in item 10975 previously provided to the person; and
(d) the person is referred to the eligible dental practitioner by the medical practitioner using a referral form that has been issued by the Department or a referral form that substantially complies with the form issued by the Department; and
(e) the person is not an admitted patient of a hospital or day‑hospital facility; and
(f) for a service for which a private health insurance benefit is payable — the person who incurred the medical expenses for the service has elected to claim the medicare benefit for the service, and not the private health insurance benefit —
to a maximum of 3 services (including any services to which this item or item 10975 or 10977 applies) in a calendar year
91.70
10977
Dental service provided to a person by an eligible dental practitioner or an eligible dental specialist (the providing dentist) if:
(a) the service is provided to a person whose dental condition is exacerbating a chronic and complex condition that is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under an EPC plan; and
(b) the service is recommended in the person’s EPC plan as part of the management of the person’s chronic and complex condition; and
(c) the service is associated with a service of the kind described in item 10975 previously provided to the person by another eligible dental practitioner; and
(d) the person is referred to the providing dentist by the eligible dental practitioner who provided the service described in item 10975 using a referral form that has been issued by the Department or a referral form that substantially complies with the form issued by the Department; and
(e) the person is not an admitted patient of a hospital or day‑hospital facility; and
(f) after the service, the providing dentist gives a written report to the referring eligible dental practitioner and the medical practitioner mentioned in paragraph (a); and
(g) for a service for which a private health insurance benefit is payable — the person who incurred the medical expenses for the service has elected to claim the medicare benefit for the service, and not the private health insurance benefit —
to a maximum of 3 services (including any services to which this item or item 10975 or 10976 applies) in a calendar year
91.70
