Document ID: chunk:federal_register_of_legislation:F2024C00744:front:0:p46
Version: federal_register_of_legislation:F2024C00744
Segment Type: other
Provision Reference: 
Character Range: 122736–125703

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.

4.3 Financial responsibility
4.3.1 Subject to paragraph 3.5.1, and unless otherwise indicated in these Principles, the Commission will accept financial responsibility for treatment costs where a general practitioner or specialist provides or arranges for treatment of:

         (a) an entitled person who has been issued with a Gold Card;or

         (b) a veteran who has been issued with a White Card for any war‑caused or other specifically listed injury or disease or for a determined condition; or

(c) a person who has been issued with a written authorisation on behalf of the Commission;

but the Commission will not accept financial responsibility for treatment costs where a general practitioner or specialist provides or arranges for treatment of a "determined residential care condition".

         Note: Principle 3.5.1 also deals with financial liability for medical practitioner fees.

4.3.2 In relation to any occasion of service to an entitled person under these Principles, a general practitioner or specialist shall bill only:

(a) the Department; or

     (b) the Commission; or

 (c) the Department of Human Services,

and that bill shall be for full settlement of the account for the service provided to the entitled person.

4.3.3 Any billing method described in paragraph 4.3.2 may be used on each occasion of service.

4.3.4 Subject to paragraph 4.7.3, the Commission will accept financial responsibility for any of the services described in paragraph 4.4.1, irrespective of the billing arrangement chosen under paragraph 4.3.2 by the referring general practitioner or specialist.

4.3A Disqualified Medical Practitioners

4.3A.1 The Commission is not to accept financial responsibility for the cost of a medical service provided to an entitled person by, or on behalf of, a general practitioner or a medical specialist if, at the time the service was 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