Document ID: chunk:federal_register_of_legislation:F2024C00744:front:0:p47
Version: federal_register_of_legislation:F2024C00744
Segment Type: other
Provision Reference: 
Character Range: 125472–128357

provided, a medicare benefit would not have been payable in respect of the service under section 19B or section 19C of the Health Insurance Act 1973 (in force from time to time) if the general practitioner or medical specialist had provided the service as a practitioner under that Act.

4.4 Referrals
4.4.1 A general practitioner may refer an entitled person for:

(a) treatment from a medical specialist, subject to paragraph 4.7.1, and principles 4.5 to 4.8;or

(b) treatment from a general practitioner who has expertise or recognition in a particular field but is not a qualified medical specialist, subject to principles 4.5 to 4.8;or

(c) treatment in a hospital or other institution as indicated in these Principles; or

(d) other health‑care services not requiring prior approval, as indicated in principles 7.3, 7.5 and 7.6.

4.5 Referrals by medical specialists
4.5.1 In providing treatment, a medical specialist, to whom an entitled person is referred under these Principles, may:

(a) arrange diagnostic tests;or

(b) refer the entitled person to another specialist in the same way as may a general practitioner;or

(c) arrange treatment in a hospital or other institution as indicated in these Principles; or

(d) refer the entitled person to a health‑care provider in accordance with principles 7.3, 7.5 or 7.6, in the same way as may a general practitioner.

4.7 Referrals: prior approval
4.7.1 In all instances other than those described in paragraph 4.7.3 and the Repatriation Private Patient Principles 2004, prior approval is required for the referral of entitled persons to medical specialists.

4.7.2 Prior approval is required for:

(a) the provision of psychotherapy treatment to entitled persons; or

(b) the provision of services under paragraph 4.2.3.

4.7.3 Prior approval is not required when a general practitioner or medical specialist refers an entitled person to a medical specialist for diagnostic imaging or pathology services not requiring admission and the medical specialist direct bills the Department of Human Services at 100 per cent or less of the fee set out in the Medicare Benefits Schedule as full settlement of the account for the service rendered.

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

4.8 Other matters
4.8.1 The Commission will not accept financial responsibility for the cost of:

(a) elective surgery undertaken without prior approval with the exception of elective surgery in a public hospital, minor procedures carried out in a general practitioner's or specialist's rooms where the only charge is equivalent to the charge that would be applicable under the Medicare Benefits Schedule for that procedure; or

(b) examination for a medical certificate for life assurance purposes; or

(c) examination for a medical certificate for membership of a friendly