16AMedicare benefits in relation to pathology services

16A Medicare benefits in relation to pathology services

(1) A medicare benefit is not payable in respect of a pathology service that has been rendered in relation to a person unless: (a) the service (whether a pathologist‑determinable service or not) was determined to be necessary by a practitioner (in this section referred to as the treating practitioner) whose patient the person was; or (aa) the service (whether a pathologist‑determinable service or not) was: (i) determined to be necessary by a participating midwife (in this section also referred to as the treating practitioner), acting in his or her capacity as a participating midwife, whose patient the person was; and (ii) a service of a kind specified in regulations made for the purposes of this subparagraph; or (ab) the service (whether a pathologist‑determinable service or not) was: (i) determined to be necessary by a participating nurse practitioner (in this section also referred to as the treating practitioner), acting in his or her capacity as a participating nurse practitioner, whose patient the person was; and (ii) a service of a kind specified in regulations made for the purposes of this subparagraph; or (b) the service was: (i) a pathologist‑determinable service rendered by or on behalf of an approved pathology practitioner; and (ii) determined to be necessary by that approved pathology practitioner. (2) A medicare benefit is not payable in respect of a pathology service (other than a prescribed pathology service to which subsection (7) or (7A) applies) unless: (a) the service was rendered by or on behalf of an approved pathology practitioner; (b) the service was rendered in an accredited pathology laboratory and was a service of a kind in respect of which the laboratory was accredited; (c) the proprietor of the laboratory was an approved pathology authority; (ca) there was no other proprietor of the laboratory; and (d) either: (i) the approved pathology practitioner by whom or on whose behalf the service was rendered was the proprietor of the laboratory; or (ii) the service was rendered in the laboratory under an agreement (whether by way of contract of employment or otherwise) between: (A) the approved pathology practitioner by whom or on whose behalf the pathology service was rendered; and (B) the proprietor of the laboratory. (3) A medicare benefit is not payable in respect of a pathology service (other than a pathologist‑determinable service to which subsection (6) applies) that has been rendered by or on behalf of an approved pathology practitioner unless: (a) the service was rendered pursuant to a request made by the treating practitioner and, if an approved pathology practitioner was specified on the request, the service was conducted by that practitioner; or (b) the service was rendered pursuant to a request made by another approved pathology practitioner who received a request for the service made by the treating practitioner and the treating practitioner did not specify a pathology practitioner. (3A) In subsection (3), a treating practitioner may only specify an approved pathology practitioner on clinical grounds. (4) A request is not effective for the purposes of subsection (3) unless: (a) the request is: (i) made in writing; or (ii) if made otherwise than in writing—confirmed in writing within the period of 14 days commencing on the day on which the request is made; and (b) the request is made in accordance with the regulations (if any). (5) A request that is made otherwise than in writing and is not confirmed in writing within the period referred to in subparagraph (4)(a)(ii) shall be deemed, for the purposes of subsection (3), never to have been made. (5AA) A medicare benefit is not payable in respect of a pathology service that has been rendered in relation to a person by or on behalf of an approved pathology practitioner (in subsection (5AB) called the rendering pathologist) pursuant to a request made by: (a) the treating practitioner; or (b) another approved pathology practitioner (in subsection (5AB) called the referring pathologist) who received a request for the service made by the treating practitioner; unless the pathology specimen required for the rendering of the service: (c) was collected from the person: (i) by the person himself or herself; or (ii) by the treating practitioner; or (iii) on behalf of the treating practitioner, by an employee of, or by a person engaged under a contract for services by or on behalf of, the treating practitioner; or (iv) if the treating practitioner is employed, or engaged under a contract for services, by a medical entrepreneur—on behalf of the treating practitioner, by another employee of that medical entrepreneur, or by a person engaged under a contract for services by or on behalf of that medical entrepreneur; or (d) was collected from the person by a person to whom this paragraph applies at: (i) the place where the person was residing; or (ii) an approved collection centre (within the meaning of Part IIA); or (iii) premises of a recognised hospital, being premises at which hospital treatment is provided; or (iv) a private hospital in which the person is a patient; or (v) a residential care home (within the meaning of the Aged Care Act 2024), or other institution, in which the person is receiving care; or (e) was collected from the person by: (i) a member of the staff of a hospital in which the person is a patient; or (ii) a member of the staff of a residential care home (within the meaning of the Aged Care Act 2024), or other institution, in which the person is receiving care. (5AB) Paragraph (5AA)(d) applies to: (a) the rendering pathologist; and (b) the referring pathologist (if any); and (c) an employee of an approved pathology authority that is the proprietor of the laboratory in which the service is to be rendered; and (d) an employee of an approved pathology authority from which the pathology specimen in question was referred to: (i) an approved pathology authority to which paragraph (c) applies; or (ii) an approved pathology practitioner who is to render the service in a laboratory of which such an approved pathology authority is the proprietor. (5A) A medicare benefit is not payable in respect of a pathology service that has been rendered by or on behalf of an approved pathology practitioner if: (a) the request for the service was made: (i) by the treating practitioner (the requesting practitioner); or (ii) by another approved pathology practitioner (the requesting practitioner) who received a request for the service made by the treating practitioner; and (b) the request for the service was made as a result of: (i) conduct in respect of which the approved pathology practitioner or the requesting practitioner has been convicted of an offence under Division 3 of Part IIBA; or (ii) conduct in respect of which the approved pathology practitioner or the requesting practitioner has been ordered to pay a pecuniary penalty under Part VIA. (6) This subsection applies to a pathology service if the service is a pathologist‑determinable service that is rendered by or on behalf of an approved pathology practitioner and the approved practitioner determines that the service is necessary. (7) This subsection applies to a pathology service if the service is a prescribed pathology service that is rendered by or on behalf of a medical practitioner (not being an approved pathology practitioner) and: (a) the medical practitioner by whom or on whose behalf the service is rendered is the treating practitioner; or (b) the medical practitioner by whom or on whose behalf the service is rendered: (i) is a member of a group of practitioners of which the treating practitioner is a member; and (ii) is requested by the treating practitioner to render the service. (7A) This subsection applies to a pathology service if: (a) the service is a prescribed pathology service that is rendered by a participating midwife or a participating nurse practitioner; and (b) the participating midwife or participating nurse practitioner by whom the service is rendered is the treating practitioner; and (c) the service is specified in the determination made under section 4BB as a service to which this subsection applies if rendered by a participating midwife or participating nurse practitioner (as the case requires); and (d) if that determination specifies circumstances in which the service must be rendered to be a pathology service to which this subsection applies—the service is rendered in those circumstances. (9) Where: (a) a practitioner conducts a medical practice or a dental practice; and (b) another practitioner, or other practitioners, participate (whether as employees or otherwise) in the provision of professional services as part of that practice; the practitioner referred to in paragraph (a) and the practitioner or practitioners referred to in paragraph (b) shall be taken, for the purposes of this section, to constitute a group of practitioners. (10) Where 2 or more practitioners conduct a medical practice or a dental practice as partners, those practitioners and any other practitioner who participates (whether as an employee or otherwise) in the provision of professional services as part of that practice, shall be taken, for the purposes of this section, to constitute a group of practitioners. (11) For the purposes of subsection (10), where 2 or more practitioners share amongst them all the income, or a substantial part of the income, from providing professional services, those practitioners shall be deemed to conduct a practice of providing those professional services as partners. (12) In this section: (a) a reference to a request made in writing or to a confirmation in writing of a request shall be read as including a reference to a request or a confirmation, as the case may be, in such other form as the Minister approves, in writing, from time to time; and (b) a reference to determining that a service is necessary is a reference to determining that a service is reasonably necessary for the adequate medical care of the patient concerned.