Referrals & Rebates - Medicare, Private Health & NDIS
Referrals
If you wish to claim the advised Medicare Rebate, you must provide a referral to your specialist that they agree is current and valid according to Medicare rules.
Referrals are the patient’s /parents’ responsibility.
We routinely provide information about the status and term of the latest referral on file for your child in the Booking Email.
It is your responsibility to read this information, monitor the term and expiry date, and seek a new referral if the term is due to expire before your next appointment or before you require any scripts or other services from your paediatric specialist.
It is your responsibility to ensure that you allow us sufficient and reasonable time, normally at least 72 hours, to resolve any validity issues or other concerns we may have and to enter and file the referral ahead of the commencement of the service (appointment).
How to know if you will 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 3 months, except for some special 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 and start date of the latest referral on file so that you can work out the expiry date:
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 monthsThis tells you that the referral will expire on 12/02/2025 if the actual start date is 13/02/ 2024. You will need to have a new referral on file for any appointment or other service from 13/02/2025 onwards.
Further examples:
your GP or specialist writes your child’s referral on 01 January 2019.
Your first appointment with the paediatrician is on 30 March 2019.
The GP’s referral will expire on 29 March 2020. (not valid on 30 March 2020)
The specialist’s referral expires on 29 June 2019 (not valid on 30 June 2019)
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 back to indefinite once it has recorded a 12-month 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 a sleep apnoea or other medical concerns.
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 make the referral of the patient.
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 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 for claiming an otherwise invalid, expired, back dated or back timed, non-current referral 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 commencement of the appointment or as soon as it is issued. We strongly prefer and recommend that referrals be provided at the time of booking.
Provision of a referral less than 3 business days before the service may result in the referral not being used for that service. We need time to check and resolve any validity issues. We need time to correctly file the referral.
The Referral Letter-Key Requirements:
It is the patient’s/ parent’s responsibility to ensure they provide a referral that is valid under Medicare Law in the opinion of the specialist being referred to.
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 and specifically advise the specialist of the concern needing their assessment;
shows the issue date;
is signed by the referring doctor, in the provider’s handwriting or as a pdf or other copy of the provider’s handwritten signature to remove any doubt of validity,
as the question of whether there’s an “electronic signature” sufficient to meet Medicare requirements is often not clear;
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.
Claiming Rebates & Medicare Eligible Services
Medicare Online Claiming
Video Appointment rebates
Advised Medicare rebates can not be claimed unless
you have provided a referral letter for your child that is valid and current under Medicare law.
your child attends the appointment
Prosper Paediatrics and your associated specialist may decline to accept and use the referral if not satisfied that it is valid or if they have not been given sufficient time to assess the validity of the referral and file it correctly.
We recommend that your referrer sends their referral by Healthlink or other Secure Messaging when they issue it or before you seek to book the appointment. Please allow us at least a week. Sending a referral less than 3 business days prior to the start of the appointment will generally not allow enough time to check or resolve any validity issues. We will do our best to resolve matters and file a referral quickly if the clinical concern is of an urgent nature.
After payment of the appointment fee, we will lodge a claim on your behalf unless you advise us otherwise. Prosper Paediatrics uses the Medicare Online System. If a valid referral has not been provided in sufficient time before the service, your doctor can generally bill an unreferred item that attracts a smaller rebate for face-to-face and some video appointments.
Your rebate will be paid into your bank account nominated to Medicare. In our experience rebates are paid within about 4 business hours but Medicare may officially advise that payment will be by the next business day. You should check that you have received the expected rebates and contact us if they have not been paid. We can usually check and correct any errors in the submitted claim. Sometimes the referral details have not been included. Sometimes the doctor has chosen an incorrect item. Sometimes you may need to call Medicare to resolve an issue.
Phone appointments are not rebated except in very limited circumstances, where an older adolescent patient conducts the call with their paediatrician.
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.
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.
GP team care plan referral is available for various allied health therapists’ appointments -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 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
Better Start referrals by your child’s paediatrician or GP.
Please see Visiting our Allied Health Professionals for more details on these plans.
Private Health Cover for Allied Health Appointments & HICAPS On-the-spot Claiming
ADF and Veteran parents
Our HICAPS terminal enables direct claiming using your Health Fund Card on the day of your allied health appointment. Levels of cover vary between and within funds so it is a good idea to contact your private health fund prior to your appointment to check if you have Extras cover for the particular service.
Private health funds do not cover appointments with medical doctors.
Where Medicare coverage is not available to a family, their overseas health fund may rebate the payment for the Doctor’s invoice. We provide a receipt you can present.
Allied Health Fees for the care of children of ADF and veteran parents are rebated by Medicare if applicable, or by your Health Fund. Our providers do not accept DVA Gold or White card for payment of their care of your child nor bill DVA directly for care provided to children under DVA arrangements. Where care is provided to a parent, the account should normally be settled and the receipts submitted to your fund or the DVA for possible reimbursement. ADF parents can access a gap cover scheme for the out of pocket costs of care of their dependent children.
National Disability Insurance Scheme (NDIS) Funding
Our 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. Paediatrics at Burnside and its providers aim to provide assistance to families so as optimise referrals and pre-planning input for their NDIS participant child.