Referrals & Rebates - Medicare, Private Health & NDIS
Referrals and Rebates
Advised Medicare rebates can not be claimed unless
you have provided a referral letter for your child that your provider judges valid and current under Medicare law.
your child attends the appointment
Referral Requirements-the patient’s responsibility
Provision of a current and valid referral is the responsibility of the patient or their parent.
To minimise difficulties, referrals should be sent
by your referrer using Healthlink or other Secure Messaging
if by a parent, by email to our admin address, or use the contact form.
at least seven business days prior to the start of the appointment.
We need time to check and resolve referral validity issues and to file the referral. If an appointment is booked on short notice due to urgent clinical concerns, we will do our best to resolve the matter and file a referral in time for that appointment.
However, generally, if a reasonable time is not allowed to resolve a referral issue or file it, the referral may not be used to claim rebates for the appointment.
If a referral cannot be filed in time, an “unreferred item” may be available to claim a smaller rebate.
How to Determine if You Need a New Referral
You will need a new referral if
The term of the latest referral will expire before the next appointment or other service;
If the latest referral is not about the CLINICAL CONCERN you wish to discuss with the specialist. Medicare rules do not allow a referral, including one with an indefinite term, to be used for a condition not included in that referral. So if your child has an indefinite referral for ASD management but wants to consult about headaches, you should supply a new referral from your GP.
The Referral Term is the time set for referral duration from the START DATE:
GPs usually write a referral for 12 months or may ask that it be for an indefinite/ ongoing term or your GP may sometimes nominate a different term.
Specialists can only write referrals that last for three months, except for certain types of referrals.
The Referral Term STARTS on the date of your first appointment under that referral.
The Start Date we advise may be the actual start date or an expected/upcoming start date
i.e., the date of the first appointment under the referral that has already happened or is scheduled in the future.
The Start Date will be on or after the Issue Date of the referral.
Our Booking Email routinely advises you about the term, start and expiry dates of the latest referral on file:
The Term is normally shown as 12 or 3 months or as “99” for an indefinite term
An example of the advised referral details provided in the Booking Email,
Your child’s Referral status is provided so you can check when you will need a new referral:
The latest referral is from Dr Jim Smith
The referral's start date is 13/02/24
The duration of the referral is 12 monthsThe expiry date is 12/02/25
If the referral on file has already expired, the expiry date is shown as 00/00/00.
Obstetrician Referrals for Newborns. This referral is for 3 months from your baby’s birth. After this time, your GP can provide a referral for your baby if needed, which will last for 12 months. Your baby’s first obstetrician referral is normally recorded in the hospital’s and doctors’ notes.
Indefinite Referrals-issues & restrictions:
Your GP’s intention as to the term of the referral must be clear and obvious. If the indefinite term is not clearly identified at the top of the letter or with similar prominence, the referral will probably be filed as a standard GP referral for 12 months. If this happens, your child will need a new referral after 12 months. Unfortunately, Medicare does not allow us to change a referral term once Medicare has recorded a referral term on its system.
Your GP must identify the clinical problems or issues included in the indefinite term.
An indefinite referral may expire
once the referred clinical issue is resolved.
your child is no longer a paediatric patient.
the referrer is no longer involved in your child’s medical care because they have retired or you do not wish them to continue in this role.
An indefinite referral may apply to particular concerns and not others. For example, the referral may be for assessment and management of ASD and will not apply for other separate developmental, mental health or medical concerns.
We recommend that GPs include all the known and current clinical concerns on any referral to avoid problems.
Which healthcare professionals can write a Medicare Referral?
Medicare only recognises referrals from Registered Medical Practitioners. Letters from your Clinical Psychologist, Occupational Therapist or other Allied Health providers often have significant clinical value but can not be used as a Medicare referral. Some Nurse Practitioners are able to make Medicare referrals, but most nurses, including CAFHs nurses, cannot.. Trainee doctors in public hospitals (interns, residents, and some registrars) generally do not have provider numbers that allow them to refer patients, and their supervising Consultant must write and sign the patient referral.
Separate referral for parents? With the prior agreement of your child’s paediatrician, a parent may use their own GP referral to see the paediatrician without the child attending to ensure access to the normal rebates.
Medicare does not permit the backdating of referrals or the use of a referral provided after the start time of the appointment.
Medicare does not permit GPs or Specialists to backdate or back-time any referral or to request a backdated referral. The lodgement of a rebate claim linked to a backdated or otherwise invalid referral is Medicare Fraud. Medicare requires that a new referral can only be used for an appointment rebate if it has been provided BEFORE the commencement of the appointment.
All document entry into our files is time-stamped and can be checked by regulators.
Sometimes, an existing, otherwise valid referral has been left at home, or the GP has forgotten to fax a previously written referral in time. In this case, families should contact their referrer before the start of their appointment to ask that a copy is sent to the specialist before the start of the appointment. However, we may not have sufficient time to check the validity and file the referral correctly for that service.
Where a valid referral is not provided, before the commencement of the appointment, the service is invoiced and then claimed against the applicable “un-referred item” and in most cases a smaller rebate can be claimed.
Any pressuring of staff to accept and use an otherwise invalid, expired, back-dated or back-timed, non-current referral for claiming is a serious breach of the Respect and Trust Policy. Your agreement and conduct in accordance with this policy are essential to the continuance of your healthcare relationship with your provider.
To avoid difficulties, validity issues, and disappointment, families are urged to ensure that a current referral has been provided at least 7 days prior to the appointment's commencement, or as soon as it is issued.
We strongly recommend that referrals be provided at the time of booking.
The Referral Letter-Key Requirements:
It is the patient’s or parent’s responsibility to ensure that they provide a referral that your provider judges valid under Medicare Law.
It is the Provider’s responsibility to ensure that any referral they rely on for their use of a Medicare item is valid. If there is doubt, Medicare Law recognises the Provider’s right to refuse the use of a referral if they have concerns about its validity in order to avoid committing Medicare Fraud.
To avoid difficulty or disappointment, please ensure that your child’s referral is
addressed to a provider by name or specialty,
e.g., Dr John Brown, “ Paediatrician” or “Paediatric Neurologist, Occupational Therapist, etc.
It is strongly recommended that the referral is addressed to a specific provider by name as this.
will be a valid referral for any provider of the same specialty and
will enable New Patient Referrals to be triaged.
shows the name of the referring doctor, their practice address and provider number;
provides a clinical reason for the referral that specifically advises the specialist of the concern or concerns needing their care;
shows the issue date;
is signed by the referring doctor, in the provider’s handwriting or with a PDF / digital copy of the provider’s handwritten signature to remove any doubt of validity,
The question of whether there’s an “electronic signature” sufficient to meet Medicare requirements is very unclear, and the regulations are incoherent;
shows an issue date and time no later than the day and start time of the appointment;
is provided before the start time of the appointment.
Medicare Rebates
Medical services and some allied health services billed using MBS/Medicare items are rebated by Medicare.
To use most MBS items, there must be a valid medical referral and the patient (the child) must be present during the consultation.
Some “unreferred items” can be sued when a valid referral has not been provided. These items allow a smaller rebate for face-to-face and some video appointments, if your child fully attends the appointment.
Phone appointments are not rebated except in very limited circumstances, where an older adolescent patient conducts the call with their paediatrician.
The selection of the appropriate item, and the decision as to whether any item can be used, is made by the provider using their professional judgement. After payment of the appointment fee, we will lodge a claim on your behalf, if possible, for the rebate for the item billed.
Prosper Paediatrics uses the Medicare Online System.
Your rebate will be paid into your bank account nominated to Medicare. In our experience, rebates are typically paid within approximately four business hours; however, Medicare may officially advise that payment will be made by the next business day.
You should check that you have received the expected rebates. If not, and it appears that there may be an issue with our claiming, please provide the problem code by email. Sometimes the referral details have not been included or the doctor has chosen an incorrect item. Sometimes you may need to call Medicare to resolve an issue.
Medicare Rebates- Standard and Safety Net
Each item has a standard rebate and these are advised in your provider’s fee schedule.
The Medicare Family Safety Net Scheme provides substantial additional rebates for families with large out-of-pocket costs in a calendar year. Most families of newborns born in private hospitals become eligible for these additional rebates in their baby’s first year. At the top eligibility threshold, Medicare pays 80% of the gap in addition to the standard rebate. We recommend that families register their family members for the Family Safety Net. Medicare provides information at http://servicesaustralia.gov.au/medicare-safety-nets
Allied Health - Medicare referral and rebates
Allied health appointments are only eligible for Medicare rebates if you have one of the following special referrals and the provider is accredited to the applicable Medicare scheme. Medicare provides for a certain number of rebates per 12 months per referral.
Referrals to accredited Psychologists and Occupational Therapists for Mental Health -up to 10 rebates.
Mental Health Care Plan (MHCP) from your GP/ or
Better Access to Mental Health Scheme Referral from your paediatrician or psychiatrist.
These referrals enable access to Medicare rebates for up to 10 visits in total per calendar year with a Psychologist and/or an accredited Occupational Therapist for therapy and assessment of mental health concerns.
GP team care plan referrals are available for various allied health therapists’ appointments, for up to 5 rebates.
Allied health includes Speech Therapist, Dietitian, Physiotherapist, Audiologist, Podiatrist, Occupational Therapist or Psychologist
Chronic Diseases Management Plan (CDMP)/Enhanced Primary Care Plan (EPC)/Team Care Arrangement (TCA) from your GP. This referral enables access to Medicare rebates for up to 5 visits per calendar year with the allied health professionals nominated in the plan. See Medicare requirements and details here.
Referral to accredited Allied Health for Developmental Diagnosis and Management Planning Input -up to 4 rebates.
-CND Complex Neurodevelopmental Disorders Scheme from your paediatrician or psychiatrist (must be claimed before your child turns 25 years of age). This referral enables access to Medicare rebates for up to 4 diagnosis/treatment planning sessions.
-Better Start for Children with Disability Initiative from your paediatrician or GP (must be claimed before your child turns 25 years of age).
Referrals to accredited therapists for up to 20 rebated sessions of therapy until age 25 for specific eligible conditions:
CND referrals can be made by your child’s Paediatrician or Psychiatrist. These provide for therapy and review by allied health in regard to Complex Neurodevelopmental concerns such as Autism.
Better Start Referrals can be made by your child’s paediatrician or GP for therapy for a number of conditions such as Downs.
Please see Visiting our Allied Health Professionals for more details on these plans.
Private Health Rebates
Private Health rebates may be available. Levels of cover vary between and within funds so it is a good idea to contact your private health fund prior to your appointment or delivery to check if you have Family Cover for neonatal care or Extras cover for the particular allied health service.
Allied Health, such as Dietitian appointments: Our HICAPS terminal enables direct claiming using your Health Fund Card on the day of your allied health appointment.
Lactation Consulting- You will need to present the receipt with a claim to your fund.
Newborn care for babies admitted in a private hospital nursery (not non-admitted babies covered by Medicare).
Families not eligible for Medicare. Where Medicare coverage is not available to a family, their overseas health fund may rebate the payment for the Doctor’s invoice. The family must pay the invoice and then present the receipt with their claim to their health fund.
Private health funds do not cover appointments with medical doctors.
Health care for children of ADF or Veteran Parents
Children of ADF or veteran parents are covered by Medicare.
Medicare provides rebates as explained above. Families should enrol their child in Medicare following birth.
Our providers do not accept DVA Gold or White cards for payment of their care for your child, nor bill DVA directly for care provided to children under DVA arrangements.
Where care is provided to a parent, the account should be settled and the receipts submitted to Defence or the DVA for reimbursement.
ADF parents can access a gap cover scheme for the out-of-pocket costs of care of their dependent children. See the information provided in the Neonatal Care menu of this website.
National Disability Insurance Scheme (NDIS) Funding
Allied health practitioners are able to provide NDIS services to children with funding packages but not all are NDIS registered. Please discuss this upon making your appointment. Provide us with your child’s NDIS details, NDIS number, and whether your funding package is agency, fund or self-managed.
Disability, developmental problems and early intervention remain core aspects of paediatric health and disability care and our providers are skilled in assessing need and guiding intervention. The associated providers aim to provide assistance to families so as optimise referrals and pre-planning input for their NDIS participant child.
NDIS funds must not be used for services provided by Medical Practitioners that are able to be rebated by Medicare.