3.2Circumstances in which prior approval is required

3.2 Circumstances in which prior approval is required

3.2.1 Treatment requiring prior approval includes:

(a) all medical specialist services in metropolitan areas;

Note: see paragraph 4.7.1.
Prior approval is not required in States or Territories where the RPPPs apply — see paragraph 1.2.2.

(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 9.1.8.

(h) respite or convalescent admission to an institution;

Note: see paragraph 9.6.1.

(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;

(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 product dispenser that is not permitted under the arrangement between the optometrist, or optical product dispenser, and the Commission or the Department;

(t) repair of a rehabilitation appliance specified as requiring prior approval in or under Part 11;

(u) chiropractic services that exceed the limits specified in paragraph 7.7.1;