3.1.1 The Commission’s prior approval may be required for treatment.
Note: Paragraph 1.5.1 provides that any approval given for treatment under the Treatment Principles revoked upon the commencement of these Treatment Principles is deemed to have been given for the purposes of, and under, these Principles.
3.2 Circumstances in which prior approval is required
(b) provision of services that are not made available under the Medicare Benefits Schedule except where otherwise stated.
Note: see paragraph 4.2.3.
(d) outpatient treatment at a private hospital where the requirement for prior approval for such treatment is specified in a contract.
(e) treatment at a hospital according to the requirements contained in section 4 of the RPPPs.
Note: where the patient is a holder of a White Card and eligibility for the treatment required is uncertain, the Commission will not accept financial responsibility for the cost of care unless the Department has verified eligibility.
(f) admission to a hospital or the provision of hospital treatment not otherwise specified;
Note: see paragraph 9.1.9.
(h) convalescent care in an institution — except where the institution is a private hospital or public hospital;
Note: for convalescent care in an institution that is a hospital see paragraph 9.5.2
(ha) respite care in an institution — except where the institution is a private hospital or public hospital;
Note: for respite care in an institution where the institution is a hospital see paragraph 10.7A.
(j) in‑home respite care;
(ja) emergency short term home relief (ESTHR) to be provided within 24 hours after a previous service of ESTHR;
Note: the intention is that 3 days (the max ESTHR per emergency) should be sufficient
time or alternative respite care to be arranged and prior approval is required before a further immediately subsequent service of ESTHR may be provided.
(k) provision of residential care in Australia or overseas;
Note: see paragraph 2.2.4 and Part 10
(n) dental treatment specified as requiring prior approval in Part 5 or in a DVA document incorporated into the Principles;
(na) diabetes educator services specified in paragraph 7.6A.2;
(o) community nursing services specified as requiring prior approval in Treatment Principle 7.3;
(p) physiotherapy that exceeds the limits specified in paragraph 7.5.1;
(q) podiatry that is not specified in paragraph 7.6.1;
(r) provision of rehabilitation appliances specified as requiring prior approval in or under Part 11;
(s) provision of a visual aid to an entitled person by an optometrist or an optical dispenser that is either:
(i) not available to the entitled person under the DVA document entitled “Pricing Schedule for Visual Aids”, referred to in Schedule 1; or
(ii) available to the entitled person under the DVA document entitled “Pricing Schedule for Visual Aids”, referred to in Schedule 1, but with the stipulation that prior approval is required.
(t) repair of a rehabilitation appliance specified as requiring prior approval in or under Part 11;
(w) ambulance transport, except for that provided by certain ambulance services specified in paragraph 12.1.1;
(x) cosmetic surgery;
(y) medical devices not included on the Department's schedule of 'Benefits Payable in Respect of Surgically Implanted Prostheses, Human Tissue Items and Other Medical Devices;
(z) psychiatric inpatient care or psychiatric day patient program care;
(za) treatment specified in any Notes for Providers (however described) and in any Fee Schedule as requiring prior approval.
3.2.2 In considering whether prior approval will or will not be given and what conditions, if any, will apply, the following will be taken into account:
(a) any specific requirements contained in these Principles or the Act;
(c) the extent of funds that are available;
(d) reasonable control over expenditure;
(e) the clinical need for the proposed treatment; and
(f) the suitability and quality of the proposed treatment.
3.3 Circumstances in which prior approval is not required
3.3.2 Treatment not requiring prior approval includes:
(a) treatment by a general practitioner except where otherwise indicated in Part 4;
(b) medical specialist consultations in country and Territory areas, except where otherwise indicated in principle 4.7;
Note: Prior approval is not required for medical specialist consultations in States or Territories where the RPPPs apply — see paragraph 1.2.2.
(c) dental treatment specified as not requiring prior approval in Part 5 or in a DVA document incorporated into the Principles;
(d) dental prosthetic treatment specified as not requiring prior approval in Part 5 or in a DVA document incorporated into the Principles;
(da) diabetes educator services, except where otherwise indicated in Principle 7.6A;
(e) the prescription and supply of pharmaceutical items as set out in Part 6;
(f) subject to paragraph 7.3.5, the provision of community nursing services by a community nurse in accordance with paragraph 7.3.3 after the services have been provided;
Note:see principle 7.3.
(fa) treatment under the Veterans' Home Care Program except a service of emergency short term home relief (ESTHR) within 24 hours of a previous service of ESTHR;
Note:see principle 7.3A.
(g) optometrical treatment provided by an optometrist to an entitled person in accordance with these Principles and the dispensing of optical products by an optometrist (or an optical dispenser) provided that, if an optical product is dispensed, any requirement for prior approval in relation to that product imposed by 3.2.1(s) is satisfied.
Note: see principle 7.4.
(h) physiotherapy treatment, except where otherwise indicated in principle 7.5.
(j) podiatry treatment, except where otherwise indicated in principle 7.6.
Note: (k) treatment at a hospital under the conditions set out in paragraph 9.1.8;
Note: (ka) convalescent care at a private hospital or public hospital;
Note: (kb) respite care in an institution — where the institution is a private hospital or public hospital.
(m) ambulance transport in an emergency or where that is the arrangement between ambulance service providers and the Commission;
Note: see paragraph 12.1.5.
(n) referral to the Australian Hearing Service; and
(o) chiropractic or osteopathic treatment.
3.4 Other retrospective approval
3.4.1 On application, the Commission may approve, and pay the cost of, any treatment that was undertaken in the period between:
(a) the effective date of eligibility under the Act; and
(b) the date on which the person is notified of entitlement.
3.4.2 The Commission may provide approval for treatment that has already been given or has commenced to be given in circumstances where:
(a) it would have accepted financial responsibility if prior approval had been sought before the service was provided; and
(b) there are exceptional circumstances justifying the failure to seek prior approval;
or where:
(c) a request for prior approval was incorrectly processed or failed to be processed due to an administrative error or processing error on the part of the Department or an officer of the Department.
3.4.3 The Commission will accept financial responsibility for emergency treatment for entitled persons and, subject to principle 2.2, for emergency treatment overseas for a war‑caused injury or disease without prior approval only if approval is sought as soon as possible after the event.
Note: this Principle does not to apply to residential care or residential care (respite) provided overseas or in Australia. In such cases the extent of Commission liability is determined under paragraphs 2.2.3 (c) and (d),
and Part 10, of the Principles.
3.4.4 The Commission’s financial liability under paragraphs 3.4.1 and 3.4.3 is limited to the difference between:
(a) the reasonable cost of treatment; and
(b) the amount that an eligible person has claimed or is entitled to claim from the Department of Human Services as a medicare benefit, a health insurance fund or another third party.
3.4.5 The Commission’s financial liability under paragraph 3.4.2 is limited to the difference between:
(a) the cost of treatment for which it is financially responsible under paragraph 3.5.1; and
(b) the amount that an eligible person has claimed or is entitled to claim from the Department of Human Services as a medicare benefit, a health insurance fund or another third party.
3.4.6 The Commission will not pay or reimburse the Medicare levy or the Medicare levy surcharge or pay or reimburse health insurance fund premiums.
Note: see the Medicare Levy Act 1986 for the Medicare levy and Medicare levy surcharge.
3.4.7 The Commission will accept financial responsibility under paragraphs 3.4.1, 3.4.2, and 3.4.3 if an application is supported by accounts, receipts, declarations or other evidence of the condition treated.
3.5 Financial responsibility
3.5.1 The extent of the financial liability accepted by the Commission for the provision of treatment to an entitled person by a health care provider is as follows:
(1) for fees charged by:
(a) a chiropractor the amount worked out under the DVA document entitled “Chiropractors Schedule of Fees”, referred to in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General Information and Section 2(b)(Chiropractors));
(b) a dentist (a Local Dental Officer)—the amount worked out under the DVA document titled “Fee Schedule of Dental Services for Dentists, Dental Specialists and other Dental Practitioners (excluding Dental Prosthetists)”, referred to in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General Information and Section 2(c) (as Section 2(c) affects dentists));
(ba) a dental hygienist, dental therapist or oral health therapist—the amount worked out under the DVA document entitled “Fee Schedule of Dental Services for Dentists, Dental Specialists and other Dental Practitioners (excluding Dental Prosthetists)”, referred to in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General Information and Section 2(c) (as Section 2(c) affects dental hygienists, dental therapists and oral health therapists));
(c) a dental prosthetist the amount worked out under the DVA document entitled “Fee Schedule of Dental Services for Dental Prosthetists”, referred to in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General Information and Section 2(c)(as section 2(c) affects dental prosthetists));
(d) a dental specialistthe amount worked out under the DVA document entitled “Fee Schedule of Dental Services for Dentists, Dental Specialists and other Dental Practitioners (excluding Dental Prosthetists)”, referred to in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General Information and Section 2(c)(as Section 2(c) affects dental specialists, including as dentists));
(e) a diabetes educator the amount worked out under the DVA document entitled “Diabetes Educators Schedule of Fees”, referred to in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General Information and Section 2(d)(Diabetes Educators));
(f) a dietitian the amount worked out under the DVA document entitled “Dietitians Schedule of Fees”, referred to in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General Information and Section 2(e)(Dietitians));
(g) an exercise physiologist the amount worked out under the DVA document entitled “Exercise Physiologists Schedule of Fees”, referred to in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General Information and Section 2(f)(Exercise Physiologists));
(h) a general practitioner the amount worked out under the DVA document entitled “Department of Veterans’ Affairs Fee Schedules for Medical Services” referred to in Schedule 1 pursuant to the following parts of that document:
Chronic Pain Honorarium Fees;
Clinical Note Fees;
Compensation Consultation Fees;
Diagnostic Imaging Fee Schedule;
Dose Administration Aid (DAA) Service Fees for General Practitioners;
General Practitioners Fee Schedule;
Guide to the Assessment of Rates of Veterans' Pensions (GARP) Fee;
Kilometre Allowance;
Medication Review Fees;
Pathology Fee Schedule;
Ready Reckoner for General Practitioners;
Relative Value Guide Fee Schedule;
Repatriation Medical Fee Schedule;
on condition that the treatment was provided in accordance with the Principles and the Notes for General Practitioners ;.
(i) a medical specialist the amount worked out under
the DVA document entitled “Department of Veterans’ Affairs Fee Schedules for Medical Services”, referred to in Schedule 1, pursuant to the following parts of that document:
Chronic Pain Honorarium Fees;
Clinical Note Fees;
Compensation Consultation Fees;
Diagnostic Imaging Fee Schedule
Dose Administration Aid (DAA) Service Fees for GPs and GPs;
Guide to the Assessment of Rates of Veterans' Pensions (GARP) Fee;
Kilometre Allowance;
Medication Review Fees;
Pathology Fee Schedule;
Ready Reckoner for GPs
Relative Value Guide Fee Schedule;
Repatriation Medical Fee Schedule;
on condition that the treatment was provided in accordance with the Principles;
(ia) a neuropsychologist — the amount worked out under the DVA document entitled “Neuropsychologists Schedule of Fees”, referred to in Schedule 1, on condition that the treatment was provided in accordance with the Principles and Notes for Allied Health Providers (Section 1 General Information and Section 2(a)(as section 2(a) affects a neuropsychologist));
(ja) an occupational therapist the amount worked out under the DVA document entitled “Occupational Therapists Schedule of Fees”, referred to in Schedule 1, on condition that the treatment was provided in accordance with the Principles, as they affect an occupational therapist other than as an occupational therapist (mental health), and the
Notes for Allied Health Providers (Section 1 General Information and Section 2(g)(Occupational Therapists));
(j) an occupational therapist (mental health) the amount worked out under the DVA document entitled “Occupational Therapists (Mental Health) Schedule of Fees”, referred to in Schedule 1, as the document relates to an occupational therapist (mental health), on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General Information and Section 2(a)(as section 2(a) affects occupational therapists (mental health));
(k) an optical dispenser of visual aids the amount worked out under the DVA document entitled “Pricing Schedule for Visual Aids”, referred to in Schedule 1, on condition that the treatment was provided in accordance with the Principles , the DVA document entitled “Pricing Schedule for Visual Aids”, referred to in Schedule 1, and the Notes for Allied Health Providers (Section 1 General Information and Section 2(h)(as section 2(h) affects optical dispensers));
(l) an optometrist the amount worked out under the DVA document entitled “Optometrist Fees for Consultation”, referred to in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General Information and Section 2(h)(as section 2(h) affects optometrists));
(m) an orthoptist the amount worked out under the DVA document entitled “Orthoptists Schedule of Fees”, referred to in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General Information and Section 2(h)(as section 2(h) affects orthoptists));
(ma) an orthotist the amount worked out under the DVA document entitled “Orthotists Schedule of Fees” referred to in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General information and Section 2(n) (Orthotists));
(n) an osteopath the amount worked out under the DVA document entitled “Osteopaths Schedule of Fees”, referred to in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the
Notes for Allied Health Providers (Section 1 General Information and Section 2(i)(Osteopaths));
(oa) an outreach program counsellor — the amount worked out under the DVA document entitled “Veterans and Veterans Families Counselling Service (VVCS) Outreach Program Counsellor Schedule of Fees”, referred to in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the VVCS OPC Provider Notes;
(p) a physiotherapist the amount worked out under the DVA document entitled “Physiotherapists Schedule of Fees”, referred to in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General Information and section 2(j)(Physiotherapists));
(q) a podiatrist the amount worked out under the DVA document entitled “Podiatrists Schedule of Fees”, referred to in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the
Notes for Allied Health Providers (Section 1 General Information and Section 2(k)( Podiatrists));
(ra) a clinical psychologist the amount worked out under the DVA document entitled “Clinical Psychologists Schedule of Fees”, referred to in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General Information and Section 2(a)(as section 2(a) affects clinical psychologist (including as a psychologist));
(r) a psychologist the amount worked out under the DVA document entitled “Psychologists Schedule of Fees”, referred to in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the
Notes for Allied Health Providers (Section 1 General Information and Section 2(a)(as section 2(a) affects psychologists (other than as a clinical psychologist));
(sa) a social worker (general) the amount worked out under the DVA document entitled “Social Workers Schedule of Fees”, referred to in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General Information and Section 2(a)(as section 2(a) affects social workers (other than as a social worker (mental health));
(s) a social worker (mental health) the amount worked out under the DVA document entitled “Social Workers (Mental Health) Schedule of Fees”, referred to in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General Information and Section 2(a)(as section 2(a) affects social workers (mental health));
(u) a speech pathologist the amount worked out under the DVA document entitled “Speech Pathologists Schedule of Fees”, referred to in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General Information and Section 2(l)(Speech Pathologists));
except where the Commission, having regard to the matters specified in paragraph 3.2.2, is satisfied that there are exceptional circumstances justifying payment of a higher fee.
3.5.2 The Commission will only accept financial responsibility for treatment:
(a) that is reasonably necessary for the adequate treatment of the eligible person;
(b) that is given by an appropriate category of health care provider; and
(c) if a claim for payment in respect of treatment:
(i) is in the form, if any, approved by the Commission for this purpose ('approved form'); and
(ii) contains, or is accompanied by, any information required by any direction in any approved form; and
(iii) is lodged at an appropriate place or with an appropriate person within the period of 2 years (or such longer period as is allowed in accordance with paragraph 3.5.2A) from the date of rendering the service to which the claim relates.
Note 1: a claim is taken to have been lodged on the day it is received.
Note 2: 'appropriate place' means an office of the Department in Australia, the Department of Human Services or a place approved by the Commission for the purpose of lodging claims.
Note 3: 'appropriate person' means a person approved by the Commission for the purpose of lodging claims.
Note 4: a claim may be lodged by means of an electronic transmission.
3.5.2A Upon application in writing, by a claimant, to the Commission, the Commission may, in its discretion, by notice in writing served on the claimant, allow a longer period for lodging a claim than the period of 2 years referred to in subparagraph 3.5.2(c).
Note: 'claimant' means an appropriate category of health provider seeking payment in respect of treatment provided under the Principles.
3.5.2B In exercising its power under paragraph 3.5.2A to allow a longer period for lodging a claim, the Commission shall have regard to all matters that it considers relevant, including, but without limiting the generality of the foregoing, any hardship that might be caused to the claimant if a longer period is not allowed.
Note: 'claimant' means an appropriate category of health provider seeking payment in respect of treatment provided under the Principles.
3.5.3 Subject to paragraph 3.5.3A, the Commission will not accept financial responsibility for the cost of the following treatment by health care providers, including treatment by dentists, physiotherapists and podiatrists:
(a) services that have been paid for, wholly or partly, by the Department of Human Services, as a medicare benefit, or by a health insurance fund; or
(b) services where the cost is otherwise recoverable, wholly or partly, by way of a legal claim; or
(c) examination for employment purposes; or
(d) examination for a medical certificate for membership of a friendly society.
3.5.3A Paragraph 3.5.3(a) does not apply to treatment that is private accommodation provided to an entitled person as a private patient in a hospital where a private health insurer of the person agrees to pay the difference between the cost of shared accommodation for the person at the hospital and the cost of the private accommodation for the person — the RPPPs covers such treatment.
Note 1: “private patient” is defined in s.90A(8) of the Act.
Note 2: this provision ensures paragraph 3.5.3(a) does not prohibit the Commission from accepting responsibility for part of the cost of private accommodation in a hospital where a private health insurer pays for the remainder of the cost.
The Commission’s responsibility in this area is regulated by the RPPPs i.e. cost‑sharing between the Commission and the entitled person or a private health insurer is worked out under the RPPPs.
3.5.4 Where the Commission accepts financial responsibility under these Treatment Principles, it does so on behalf of the Commonwealth.