PART 7 — TREATMENT GENERALLY FROM OTHER HEALTH PROVIDERS
7.1 Prior approval and financial responsibility for health services
7.1.1 Except where provided in:
(1) the Principles;
(2) the Notes for Allied Health Providers; or
(3) a Fee Schedule;
the Commission’s prior approval for a treatment under this Part is not required.
7.1.1A In relation to any occasion of service to an entitled person under these Principles, except an occasion of service that is a service under the Veterans' Home Care Program, a health provider shall bill only the Department and that bill shall be for full settlement of the account for the service provided to the entitled person but in relation to any occasion of service to an entitled person under these Principles that is the provision of a service under the Veterans' Home Care Program, a health provider shall bill the Department but not for any co‑payment payable by an entitled person to the health provider and the bill presented to the Department shall be for full settlement of the account for the service provided to the entitled person.
7.1.2 Subject to these Principles and in addition to services provided under principle 2.6 and paragraph 5.1.3, the Commission may provide, arrange, or accept financial responsibility for the following:
(a) audiology
(aa) diabetes educator services;
(b) dietetics;
(c) chiropractic services;
(d) community nursing;
(dd) exercise physiology;
(e) occupational therapy;
(f) optometry;
(g) orthoptics;
(ga) orthotic services;
(h) osteopathic services;
(i) Home Care service (category A); Home Care service (category B);
(j) physiotherapy;
Note: Physiotherapy includes hydrotherapy (see paragraph 1.4.1)
(k) podiatry;
(l) psychology;
(m) social work;
(n) speech pathology.
7.1.3 The Commission will not accept financial responsibility for a service listed in paragraph 7.1.2 for an entitled person receiving residential care if the Commission is satisfied that it is more appropriate that the service is provided by the owner or operator of the residential care facility because, due to assistance (financial or otherwise) received by the owner or operator of the residential care facility under Commonwealth, State or Territory legislation, it is fair for the owner or operator of the residential care facility to bear the cost of supplying the service.
Note: For example, if the Commission is taken to have accepted financial responsibility for amounts in respect of the entitled person’s residential care under Part 10 on the basis that those amounts are intended to cover services listed in paragraph 7.1.2, the Commission will not also accept financial responsibility for those services under paragraph 7.1.2.
7.1.4 Treatment in an entitled person’s home may be approved where the entitled person is medically unable to attend the relevant facilities or where the entitled person is entitled to treatment at home under the Veterans' Home Care Program.
7.1A Notes for Providers
7.1A.1 In order for the Commission to be taken to have arranged treatment provided to an entitled person by a health care provider in an item (denoted by a number) in Column A below, the treatment must have been provided in accordance with the section of the Notes for Allied Health Providers or with the VVCS OPC Provider Notes, as the case may be, for that item in Column B below:
7.1B.1 The Commission is not to accept financial responsibility for the cost of a service provided to an entitled person by, or on behalf of, a health care provider if, at the time the service was provided, a medicare benefit would not have been payable in respect of the service under section 19B of the Health Insurance Act 1973 (in force from time to time) if the health care provider had provided the service as a practitioner under that Act.
7.2 Registration or enrolment of providers
7.2.1 Where a provider of a service specified in principle 7.1 (other than a service of community nursing) is practising in a State or Territory that has legislation requiring the registration of the occupation, the provider must be registered under that legislation.
Note: the occupational registration of DVA‑contracted community nursing providers is dealt with in the arrangements between the Commission and DVA‑contracted community nursing providers.
7.2.2 Where a State or Territory does not have legislation concerning registration, a provider of a service specified in principle 7.1 (other than a service of community nursing) must be registered in another State or possess qualifications that would permit registration in another State or must be registered in another Territory or possess qualifications that would permit registration in another Territory, if that other State or other Territory has legislation requiring the registration of the occupation in question
Note: the occupational registration of DVA‑contracted community nursing providers is dealt with in the arrangements between the Commission and DVA‑contracted community nursing providers.
7.2.3 Where the provider of a service specified in principle 7.1 (other than a service of community nursing) is a corporate entity and is practising in a State or Territory that has legislation enabling registration of the corporate entity, both the person actually delivering the service and the corporate entity must be registered under the relevant legislation.
Note: the occupational registration of DVA‑contracted community nursing providers is dealt with in the arrangements between the Commission and DVA‑contracted community nursing providers.
7.3 Community nursing
7.3.3 The Commission will accept financial responsibility for community nursing services for an entitled person only if:
(a) the person has been referred to a community nursing provider by a general practitioner, a treating doctor in a hospital, a hospital discharge planner, an authorised nurse practitioner, or a VHC assessment agency; and
Note: paragraph 7.3.6 sets out the community nursing provider to whom an entitled person can be referred under paragraph 7.3.3(a).
(b) a community nursing provider, pursuant to an arrangement with the Commission, has undertaken a nursing assessment of the entitled person prior to the commencement of care and assessed that the person has a clinical need or a personal care need, or both, for the community nursing service.
7.3.4 All of an entitled person’s care documentation prepared by a community nursing provider shall be provided to the Department upon request by the Department to the community nursing provider.
7.3.5 An entitled person whose care needs, due to their complexity and care regime, are significantly outside of the scope of the community nursing classification to which they belong, is treated under the exceptional case process. Before a person can be treated under the exceptional case process, prior approval must be obtained from the Commission.
7.3.6 A referral to a community nursing provider is to be made only to a community nursing provider that has entered into, and is bound by, an agreement with the Commission or the Department to provide community nursing services during the relevant period of treatment and in the geographical area in which the entitled person resides.
7.3.6A If no community nursing provider referred to in paragraph 7.3.6 can provide the relevant community nursing care within a reasonable time, the Commission may approve a referral to another community nursing provider.
7.3.7 The Commission will not accept, as part of a community nursing service, financial responsibility for any domestic help services such as cooking, shopping, cleaning, laundry, transport and companionship.
7.3AA Sustainability payments—community nursing
7.3AA.1 This subpart deals with a quarterly payment made to a community nursing provider (a sustainability payment):
(a) for the costs incurred by the provider in delivering care coordination and management necessary for the provision of a community nursing service; and
(b) that is to be paid between 1 July 2024 and 30 June 2026.
7.3AA.2 The Commission will, on its own initiative, pay a sustainability payment to a community nursing provider, for a quarter between 1 April 2024 and 31 March 2026 (the claim processed period), if:
(a) the provider delivers a community nursing service under the program to an entitled person in accordance with this Part; and
(b) the service is delivered under an agreement with the Commission that is in force at the time the eligibility for the payment is determined; and
(c) a claim for payment for the service is approved during the quarter.
7.3AA.3 A sustainability payment for a quarter within the claim processed period that is payable to a community nursing provider under paragraph 7.3AA.2 is worked out using the following steps:
(a) work out the number of entitled people who received from the provider a community nursing service for which a claim for payment was approved in each calendar month during the quarter;
(b) multiply the number worked out under paragraph (a) by the amount determined, in writing, by the Commission for this paragraph.
7.3AA.4 To remove any doubt, for the purposes of paragraph 7.3AA.3(a), an entitled person is counted once for a calendar month even if more than one claim for payment was approved in the calendar month for community nursing services that the person received from the provider.
7.3A Veterans' Home Care Program
7.3A.1 (1) The Commission may:
(a) examine the circumstances of an entitled person and assess the suitability of the person for:
(i) a Home Care service (category A); or
(ii) a Home Care service (category B); or
(iii) pursuant to a GP Home Care service (category C) Referral, a Home Care service (category C).
Note: the Commission has delegated its assessment power to a contractor known as a VHC assessment agency.
(2) The Commission may determine that an assessment made under paragraph (1) is to be effective from a date before or after the date on which the assessment is made.
(3) The Commission shall ensure a record is made of any assessment under paragraph (1) and any determination under paragraph (2).
(4) A record under paragraph (3) may be made and maintained in electronic form.
7.3A.3 (1) An entitled person is not entitled to a service of Home and Garden Maintenance if the provision of the service would mean the person had received Home and Garden Maintenance for a period or periods that would exceed, or cumulatively exceed, 15 hours over the relevant period.
7.3A.3 (2) For the purposes of paragraph 7.3A.3 (1), the relevant period is a period of 12 months commencing on the date when the Commission accepted financial liability for the provision of Home and Garden Maintenance to the entitled person, or on the anniversary of that date.
Note: the intention is that unused hours of Home and Garden Maintenance in a 12 month period are not carried over into the next 12 month period.
7.3A.4 Outcome of Assessment
(1) Where under 7.3A.1(1) the Commission decides that an entitled person is not suitable for a relevant service, it shall inform the entitled person accordingly and give reasons for its decision.
(2) Where under 7.3A.1(1) the Commission decides that an entitled person is suitable for a relevant service, it shall:
(a) determine the type, duration and frequency of the service;
(b) in the case of a Home Care service (category A) or a Home Care service (category C) — allocate responsibility for providing the service to an appropriate approved provider; and
(c ) in the case of a Home Care service (category B) — provide the service.
Note (1): in practice the Commission may delegate its power to assess a person’s suitability for a service to contractors (called VHC assessment agency).
Note (2): The Commission may also delegate its power to allocate the task of providing any “category A or C service” to contractors (called a VHC assessment agency).
Note (3): The Commission may delegate its power to provide a Home Care service (category B) to a contractor (e.g. an instrumentality of a State or Territory).
Note (4): Contractors may, in turn, sub‑contract the responsibility to provide a relevant service.
7.3A.4A An approved provider may provide a Home Care service (category A), a Home Care service (category B) or a Home Care service (category C) to an entitled person.
7.3A.5 The Commission may accept financial responsibility for the provision of a Home Care service (category A) to an entitled person by an approved provider if the service is supplied:
(i) in accordance with the arrangement between the approved provider and the Commission; and
(ii) in accordance with the terms of a decision under paragraph 7.3A.1(1) that the entitled person is suitable for the service; and
(iii) in accordance with the Principles.
7.3A.6 The Commission may accept financial responsibility for the provision of a Home Care service (category B) to an entitled person by the Commission.
Note: in practice the Commission may delegate its power to assess "Home Care need" to a contractor and may delegate its power to supply a Home Care service (category B) to a contractor. Those contractors may, in turn, sub‑contract the obligation to supply the relevant services.
7.3A.6B The Commission may accept financial responsibility for the provision of a Home Care service (category C) to an entitled person by an approved provider, for a period of care provided by a general practitioner to the entitled person under the Coordinated Veterans' Care Program, if:
(1) the approved provider has an arrangement with the Commission or the Department to provide a Home Care service (category A) or Home Care service (category B) to an entitled person; and
(2) the service has been requested for the person by a VHC assessment agency pursuant to a GP Home Care service (category C) Referral and pursuant to an assessment by the agency of the person’s suitability for the service; and
(3) the service is in accordance with the request from the VHC assessment agency; and
Note: it will be the VHC assessment agency’s responsibility to inform the approved provider of the terms on which the service is to be provided e.g. frequency of service.
(4) the service is in accordance with any requirements in the Notes for Coordinated Veterans' Care Program Providers (Notes) that relate to an approved provider delivering a Home Care service (category C) to an entitled person; and
(5) the entitled person is otherwise entitled to the service and is not, at the time of the service, receiving residential care; and
(6) the service is not essentially the same as a Home Care service (category A) or Home Care service (category B)
the person is entitled to receive.
7.3A.7 For the purposes of the Principles, an approved provider is deemed to be a health care provider.
7.3A.8 Subject to paragraph 7.3A.9, a condition of any arrangement between the Commission and an approved provider for the provision of a Home Care service (category A) or Home Care service (category C)
to an entitled person by the approved provider or any sub‑contractor engaged by it, is that:
(a) the approved provider, and any such sub‑contractor, shall not demand, receive or assign, an amount from the entitled person in relation to the provision of the Home Care service (category A) or Home Care service (category C) that exceeds $5 per hour of service; and
(b) the approved provider, and any such sub‑contractor, shall not demand, receive or assign a proscribed amount from the entitled person in relation to the provision of the Home Care service (category A) or Home Care service (category C).
7.3A.9 For the purposes of paragraph 7.3A.8, in relation to a proscribed amount that is an exempt amount, it is only a condition of an arrangement not to demand, receive or assign such a proscribed amount if the Commission has made a determination under paragraph 7.3A.10 and notified the approved provider, whether by electronic means or otherwise, of the effect of that determination.
7.3A.10 Pursuant to a request in writing from an entitled person or an approved provider, the Commission shall determine whether, in the opinion of the Commission, an entitled person is or is not an exempt entitled person and such a determination shall be recorded in writing and shall be prima facie evidence of the matters contained therein.
Note: an exempt entitled person is not required to pay an amount the person would otherwise be required to pay to an approved provider in respect of a Home Care service (category A) or Home Care service (category C).
7.3A.11 Where:
(a) under paragraph 7.3A.8, an entitled person cannot be required to pay an amount of money in respect of a Home Care service (category A) or Home Care service (category C) provided or to be provided to that person by an approved provider or a sub‑contractor, because:
(i) the person is an exempt entitled person; or
(ii) the Home Care service (category A) or Home Care service (category C) provided or to be provided to the entitled person is a similar service to a Home and Community Care Program service the entitled person received immediately before 1 January 2001 and in respect of which the entitled person had not been required to pay a charge ("similar service no charge"); or
(iii) the Home Care service (category A) or Home Care service (category C) provided or to be provided to the entitled person is a similar service to a Home and Community Care Program service the entitled person received immediately before 1 January 2001 and in respect of which the entitled person had been required to pay a charge ("similar service some charge") but the amount of money that could have been required of the person under the Veterans' Home Care Program, but for it being a proscribed amount, exceeds that charge; and
(b) a Home Care service (category A) or Home Care service (category C) is provided to the entitled person by an approved provider or a sub‑contractor;
the Commission will accept responsibility to pay to the approved provider in respect of the Home Care service (category A) or Home Care service (category C):
(c) in the case where the entitled person could not be required to pay an amount because the person was an exempt entitled person — an amount equal to the amount the person could have been required to pay if the person had been an entitled person who was not an exempt entitled person;
(d) in the case where the entitled person could not be required to pay an amount because the person was provided with a "similar service no charge" — an amount equal to the amount the person could have been required to pay if the Home Care service (category A or Home Care service (category C) provided to the entitled person had not been a "similar service no charge";
(e) in the case where the entitled person could not be required to pay a certain amount because the person was provided with a "similar service some charge" and the amount the person could not be required to pay was a proscribed amount because it exceeded the amount the person was charged when the person received the Home and Community Care Program service on which the "similar service some charge" was based — an amount equal to that proscribed amount;
Note: it is the intention that the Commission accept responsibility for a proscribed amount referred to in paragraph (f) of the definition of "proscribed amount" (part of charge per hour) and not for the proscribed amount referred to in paragraph (b) of the definition of "proscribed amount" (amount exceeding maximum amount payable weekly or over a longer period).
7.3A.12 A condition of any arrangement between the Commission and an approved provider for the provision of a Home Care service (category A) to an entitled person by the approved provider or any sub‑contractor engaged by it, is that a Home Care service (category A) will not be provided to an entitled person receiving residential care under the Aged Care Act 2024 including where the Commission accepts financial responsibility for the provision of that residential care pursuant to the Principles.
7.3A.13 The prior approval of the Commission for:
(a) the provision of a Home Care service (category A) to an entitled person by an approved provider;
(b) the provision of a Home Care service (category B) to an
entitled person by an approved provider; or
(c) the provision of a Home Care service (category C) to an entitled person by an approved provider;
is not required except that in the case of the provision of a Home Care service (category A) to an entitled person by an approved provider that is emergency short term home relief (ESTHR), the prior approval of the Commission is required for the provision of ESTHR within 24 hours after a previous service of ESTHR.
Note: the fact that the Commission's prior approval for treatment is not required does not mean an assessment is not required.
Transitional
7.3A.14 For the purposes of paragraph 7.3A.15:
"former service", in relation to an entitled person, means any Home and Community Care Program service the person was receiving immediately before 1 January 2001 or after 1 January 2001 and immediately before the person seeks services under the Veterans' Home Care Program.
7.3A.15 (1) An entitled person who was receiving a former service is entitled to receive whichever of Home Care service (category A) services or of Home Care service (category B) services is the most similar to that former service if the Commission assesses the person as needing one of those services.
(2) Upon the Commission deciding a person in paragraph (1) is entitled to a Home Care service (category A) or a Home Care service (category B), then the entitlement of that person to the service is subject to the Principles.
7.3A.16 Where a decision is made under paragraph 7.3A.15 (1), including a decision not to provide a service, the Commission shall make a record of the decision and give notice of the decision to the entitled person.
Note: a decision may be recorded in electronic form and notice of the decision may be given in electronic form.
7.3A.17 Upon the Commission making a decision under paragraph 7.3A.15 (1), the entitled person's entitlement, if any, to a Home Care service (category A), or to a Home Care service (category B), has effect subject to that decision.
Limited VHC‑type services for dependants and former dependants
7.3A.19A Definitions
For the purposes of paragraphs 7.3A.19A to 7.3A.22 (inclusive):
eligible person means a person who is eligible for a service.
service means a limited VHC‑type service.
widow(er) means a widow or a widower.
7.3A.19 Subject to paragraph 7.3A.21, the Commission may accept financial responsibility for the provision of a limited VHC‑type service to a person eligible to receive the service.
7.3A.20 A person eligible for a limited VHC‑type service is a person who the Commission decides is:
(a) an entitled widow(er) of a deceased entitled veteran in circumstances where the deceased entitled veteran was, at or about the time of death, being provided with Domestic Assistance or Home and Garden Maintenance or both; or
Note: Eligibility for a limited VHC‑type service (treatment) is conferred on dependants by express provisions in Part V of the Act or by Determination 7/2001 made under paragraph 88A(1)(b) of the Act.
(b) an entitled person who is a child of a deceased entitled veteran in circumstances where the deceased entitled veteran or the deceased entitled widow(er) of the deceased entitled veteran, was, at or about the time of death, being provided with Domestic Assistance or Home and Garden Maintenance or both; or
Note: "child" under the Act has a different meaning to its normal meaning and means a person who has not turned 16 unless the person is undertaking full time education in which case the person is a child until turning 25.
(c) an entitled person who is a former child of a deceased entitled veteran in circumstances where the deceased entitled veteran or the deceased entitled widow(er) of the deceased entitled veteran, was, at or about the time of death, being provided with Domestic Assistance or Home and Garden Maintenance or both and the former child is a person with a serious disability; or
Note: "child" under the Act has a different meaning to its normal meaning and means a person who has not turned 16 unless the person is undertaking full time education in which case the person is a child until turning 25. Accordingly a child of a veteran ceases to be a child of the veteran upon turning 16 or 25, as the case may be. The child is then a former child of the veteran.
(d) an entitled person who is a former child of a deceased entitled veteran in circumstances where the deceased entitled veteran or the deceased entitled widow(er) of the deceased entitled veteran, was, at or about the time of death, being provided with Domestic Assistance or Home and Garden Maintenance or both and the former child was a full‑time carer of the deceased entitled veteran or entitled widow(er) immediately prior to the death of the entitled veteran or the entitled widow(er), as the case may be; or
Note: "child" under the Act has a different meaning to its normal meaning and means a person who has not turned 16 unless the person is undertaking full time education in which case the person is a child until turning 25. Accordingly, a child of a veteran ceases to be a child of the veteran upon turning 16 or 25, as the case may be. The child is then a former child of the veteran.
(e) an entitled person who is the partner of an entitled veteran ("veteran") and who resided with that veteran immediately before the veteran needed to leave the home in order to receive treatment and at or about the time of the veteran's departure, the veteran was being provided with Domestic Assistance or Home and Garden Maintenance or both.
(f) either: (i) a child of an entitled veteran; or
(ii) a former child of an entitled veteran;
who resided with the entitled veteran or with the entitled widow(er) of a deceased entitled veteran immediately before the entitled veteran or entitled widow(er) needed to leave the home in order to receive treatment and at or about the time of the departure of the entitled veteran or entitled widow(er):
(iii) the entitled veteran or entitled widow(er) was being provided with Domestic Assistance or Home and Garden Maintenance or both; and
(iv) in the case of a former child of an entitled veteran residing with the veteran or the entitled widow(er) of the veteran, the former child was a person with a serious disability or was the full‑time carer of the entitled veteran or of the entitled widow(er) of the veteran;
7.3A.21 The conditions on which the Commission will accept financial responsibility for the provision of a limited VHC‑type service to a person eligible to receive the service are:
(1) in respect of an eligible person in paragraph 7.3A.20 (a) — the service is provided for a period of no longer than 12 weeks commencing on the day after the day on which the entitled veteran died ("commencement day"), unless, within the period of 12 weeks commencing on the commencement day, the person claims a pension under Part II of the Act in which case the service is provided for no longer than the period commencing on the commencement day and ending at the end of the day on which the Department notifies the Commission of the outcome of the claim.
Note (1): in practice a Commission delegate will determine a claim and the Department will communicate details of the determination to the delegate of the Commission who arranged provision of the limited VHC‑type service.
Note (2): in practice the Commission will be a delegate exercising the Commission's assessment powers.
Note (3): notification can be orally or in writing including in electronic form.
(2) in respect of an eligible person in paragraphs 7.3A.20 (e) or (f), the service is provided over a period no longer than 12 consecutive weeks commencing on the day the entitled veteran or entitled widow(er), as the case may be, left the home for treatment.
(3) the service is identical to either Domestic Assistance or Home and Garden Maintenance (or both) that the relevant entitled veteran or entitled widow(er) was receiving at or about the time of his or her death or at or about the time of his or her departure from the home for treatment, as the case may be.
(4) the service is provided on the same terms, including any liability to make a co payment, that the Domestic Assistance or Home and Garden Maintenance (or both) was provided to the relevant entitled veteran or entitled widow(er) at or about the time of his or her death or at or about the time of his or her departure from the home for treatment, as the case may be.
(5) the eligible person resided in the home of the relevant entitled veteran or relevant entitled widow(er) at the time of the death of the relevant entitled veteran or relevant entitled widow(er) or at the time the relevant entitled veteran or relevant entitled widow(er) departed from the home for treatment, as the case may be.
(6) in order for an eligible person referred to in paragraph 7.3A.20 (d) to be provided with a service, the eligible person must have been:
(a) the full‑time carer of the entitled veteran immediately prior to the death of the veteran; or
(b) must have been the full‑time carer of the entitled widow(er) of the deceased entitled veteran immediately prior to the death of the widow(er);
at or about the time the service is required.
Note: the intention is to ensure that a former child satisfies eligibility criteria for a sevice by reference to his or her current situation and not to a previous one. For example, a former child may, in the past, have been a full‑time carer of a deceased entitled veteran who received a service. The former child then resided with the widow(er) of the deceased veteran and the widow(er) received a service. The widow(er) then dies or leaves the home for treatment but the former child is only eligible for a service if the child was the full‑time carer of the widow(er). If not, and the former child cannot satisfy any other grounds of eligibility, then the former child is not eligible for a service.
7.3A.22 For the purposes of paragraph 7.3A.21, a particular veteran or widow(er) is a "relevant entitled veteran" or "relevant entitled widow(er)" in relation to a particular eligible person, where the eligible person was residing with that veteran or that widow(er) at the time of the death of the veteran or widow(er) or at the time of the departure of the veteran or widow(er) from the home for treatment, and the eligible person is relying on that fact as constituting an element necessary to establish the basis for the person's entitlement to a service.
Note (1): the intention is to ensure that the conditions for providing a service to an eligible person are related to that person's particular circumstances. For example, a former child who resided with an entitled widow before her death is only entitled to the domestic‑type assistance that widow was receiving and is not entitled to the domestic‑type assistance some other widow was receiving. Similarly, the former child is not entitled to Home and Garden‑type maintenance if the widow had not been receiving Home and Garden Maintenance. The entitlement of the eligible person is to reflect the entitlement of the primary beneficiary (entitled veteran, including deceased entitled veteran, or entitled widow(er)).
Note (2): in the case of a child or former child, it is that person's relationship with a veteran, as distinct from a relationship with a veteran's widow or widower, that establishes the eligibility of the child or former child to treatment.
7.3B Sustainability payments—Veterans’ Home Care Program
7.3B.1 This subpart deals with a quarterly payment made to an approved provider for the Veterans’ Home Care Program (a sustainability payment):
(a) for the costs incurred by the provider in delivering care coordination and management necessary for the provision of a service under the program; and
(b) that is to be paid between 1 July 2024 and 30 June 2026.
7.3B.2 The Commission will, on its own initiative, pay a sustainability payment to an approved provider, for a quarter between 1 April 2024 and 31 March 2026 (the claim processed period), if:
(a) the provider delivers a service under the program to an entitled person in accordance with this Part; and
(b) the service is delivered under an agreement with the Commission that is in force at the time the eligibility for the payment is determined; and
(c) a claim for payment for the service is approved during the quarter.
7.3B.3 A sustainability payment for a quarter within the claim processed period that is payable to an approved provider under paragraph 7.3B.2 is worked out using the following steps:
(a) work out the number of entitled people who received from the provider a service under the program for which a claim for payment was approved in each calendar month during the quarter;
(b) multiply the number worked out under paragraph (a) by the amount determined, in writing, by the Commission for this paragraph.
7.3B.4 To remove any doubt, for the purposes of paragraph 7.3B.3(a), an entitled person is counted once for a calendar month even if more than one claim for payment was approved in the calendar month for services that the person received from the provider.
7.4 Optometrical services
7.4.1 The Commission may accept financial responsibility for optometrical services provided by an optometrist (with a current provider number) to an entitled person in accordance with these Principles and the
Notes for Allied Health Providers (Section 1 General Information and Section 2(h)(as section 2(h) affects optometrists)).
7.4.2 The Commission may accept financial responsibility for optometrical products provided by an optical dispenser (who may be an optometrist) to an entitled person if those products have been provided in accordance:
(a) the Principles; and
(b) the Notes for Allied Health Providers (Section 1 General Information and Section 2(h)(as section 2(h) affects optometrists and optical dispensers)); and
(c) the DVA document entitled “Pricing Schedule for Visual Aids”, referred to in Schedule 1.
7.4.3 Optometrical products are those referred to in the DVA document entitled “Pricing Schedule for Visual Aids”, referred to in Schedule 1
Note:The Pricing Schedule for Visual Aids is available at any office of the Department.
7.4.4 An optometrist or optical dispenser may render the account for services provided to an entitled person either to the Department or to the Department of Human Services under the direct billing arrangements.
7.4.5 When an optometrist or optical dispenser direct bills the Department of Human Services and visual aids are prescribed, these may be provided under paragraph 7.4.2.
7.5 Physiotherapy
7.5.1 The Commission will accept, subject to paragraph 7.5.3, financial responsibility for physiotherapy treatment for a period, where a general practitioner or medical practitioner refers an entitled person to a registered physiotherapist who has a provider number.
Note: Physiotherapy includes hydrotherapy (see paragraph 1.4.1).
7.5.2 The period referred to in paragraph 7.5.1 commences on the date of the general practitioner’s, or medical specialist’s, referral.
7.5.3 Prior approval is required for physiotherapy treatment where those services are to be provided in a public hospital.
7.5.4 The Commission may accept financial responsibility for hydrotherapy treatment that does not include recreational water exercises or recreational swimming.
7.6 Podiatry
7.6.1 Subject to paragraph 7.6.6, the Commission will accept financial responsibility for podiatry treatment where a general practitioner or medical specialist refers an entitled person to a registered podiatrist who has a provider number for an episode of care.
7.6.2 Prior approval is required for podiatry treatment:
(b) where those services are to be provided in a public hospital; or
(c) involving providing an Electrodynographic Analysis and Report; or
(d) involving delivering services valued at over $60 under the Miscellaneous Items listed in the Deed of Agreement between the Commission and the podiatrist.
7.6.3 The Commission will accept financial responsibility for surgical removal of the toenail plate (either partial or total) by a registered podiatrist who has a provider number, with or without sterilisation of the matrix, only if prior approval has been obtained.
7.6.5 The Commission will accept financial responsibility for footwear, and footwear repairs, only if the footwear is:
(a) medical grade footwear;
(b) prescribed by a registered podiatrist, or a medical specialist who is a rehabilitation specialist, orthopaedic surgeon or rheumatologist; and
(c) provided by a supplier approved by the Commission.
7.6.6 Except where the Commission decides otherwise, financial responsibility will not be accepted for routine toenail cutting.
7.6A Diabetes Educator services
7.6A.1 Subject to paragraph 7.6A.2 the Commission may accept financial responsibility for diabetes educator services provided to an entitled person with diabetes where:
(a) a referer, being a general practitioner, medical specialist, discharge planner, a treating doctor in a hospital or another diabetes educator with a current referral, refers the entitled person to a diabetes educator for diabetes educator services; and
(b) except where the referer is of the opinion that the entitled person suffers from chronic diabetes that needs ongoing treatment, twelve months has not elapsed from the date of the referral or, where an entitled person is referred by a diabetes educator to another diabetes educator, twelve months has not elapsed from the date of the original referral; and
(c) the diabetes educator has a provider number.
7.6A.2 Prior approval is required for diabetes educator services where those services are to be provided to an entitled person in a public hospital.
7.7 Chiropractic and osteopathic services
7.7.1 The Commission will accept financial responsibility for chiropractic or osteopathic services where a general practitioner or medical specialist refers an entitled person to a registered chiropractor or osteopath who has a provider number.
7.7.2 The Commission will only accept financial responsibility for chiropractic and osteopathic services involving treatment of the musculo‑skeletal system. No other treatment will be accepted.
7.7.3 The Commission will only accept financial responsibility for x‑rays taken by a registered chiropractor who is licensed to take x‑rays under relevant State or Territory legislation.
7.7.5 The Commission will not accept financial responsibility for the provision of concurrent courses of physiotherapy and chiropractic services or physiotherapy and osteopathic services for the same condition to any entitled person.
7.7A Outreach Program Counselling
7.7A.1 The treatment of outreach program counselling is established under this Part and may be provided by an outreach program counsellor to an eligible person in accordance with the Principles.
Note 1: paragraph 7.1A.1 requires outreach program counselling to be provided in accordance with the VVCS OPC Provider Notes.
7.7A.2 A person is eligible for outreach program counselling if:
(a) the person is eligible for VVCS under the Act; and
(b) in the opinion of the Commission:
(i) the person is unable to reasonably have access to a VVCS Centre due to the physical isolation of the person’s place of residence in Australia; or
(ii) despite the person having reasonable access to a VVCS Centre, there is a special reason for the person requiring outreach program counselling; and
(c) the outreach program counselling is provided to the person by an outreach program counsellor pursuant to a referral from the Veterans and Veterans Families Counselling Service.
7.7A.4 For paragraph 7.1.1, prior approval for outreach program counselling is not required.
7.8 Other services
7.8.1 The Commission will not accept financial responsibility for certain services, including:
(a) herbalist services;
(b) homeopathy;
(c) iridology;
(d) massage that is not performed as part of authorised physiotherapy, chiropractic or osteopathy services; and