Treatment Principles (No. R52/2013)
4.2Providers of services
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4.2 Providers of services
4.2.1 Unless otherwise indicated in these Principles, an entitled person may be provided with only those services included in the Medicare Benefits Schedule.
4.2.2 The services referred to in paragraph 4.2.1 may be provided only by:
(a) a general practitioner; or
(b) a medical specialist.
4.2.3 (1) An entitled person may be provided with services that are not made available under the Medicare Benefits Schedule or the Department of Veterans’ Affairs Fee Schedules for Medical Services (unlisted services).
(2) Unlisted services are not to be provided to an entitled person if the Commission is satisfied that they are:
(a) a mere improvement on existing Medicare Benefits Schedule listed services; or
(b) experimental and have not been demonstrated to be effective or safe by extensive clinical trials.
4.2.4 Subject to paragraph 4.2.3(2), unlisted services are to be provided to an entitled person under paragraph 4.2.3(1) if the Commission is satisfied that the services will provide a substantial benefit to the health of the entitled person.
Note 1: the prior approval of the Commission is required before unlisted services may be provided (Paragraph 3.2.1 (b)).
Note 2: the availability of funds and the need to reasonably control expenditure are factors to be considered in granting prior approval (Subparagraphs 3.2.2 (c) and (d))
4.2.5 The services referred to in paragraph 4.2.3 may be provided only by:
(a) a general practitioner; or
(b) a medical specialist.
4.2.6 Optical Coherence Tomography
4.2.7 The Commission may accept financial responsibility for Optical Coherence Tomography (OCT) provided to an entitled person by an Ophthalmologist for the assessment or management of retinal disease.
Note: While OCT remains an unlisted treatment it is subject to all the requirements for an unlisted treatment except prior approval.
4.2.8 DVA Fee Schedule Services
4.2.9 Despite paragraph 4.2.1, an entitled person may be provided with services included in the Department of Veterans’ Affairs Fee Schedules for Medical Services.
4.2.10 Services provided under paragraph 4.2.9 may be provided only by a general practitioner or a medical specialist.
4.2.11 Prior approval is not required for services provided under paragraph 4.2.9.