HEALTH INSURANCE ACT 1973 - SECT 16B Medicare benefits in relation to R - type diagnostic imaging services
HEALTH INSURANCE ACT 1973 - SECT 16B
Medicare benefits in relation to R - type diagnostic imaging servicesGeneral rule--request required for services
(1) Subject to subsections (6), (7), (8), (9), (10) and (11), a medicare benefit is not payable in respect of an R - type diagnostic imaging service rendered in relation to a person by or on behalf of a medical practitioner (in this section called the providing practitioner ) unless:
(a) where the service is one for which there is a corresponding NR - type diagnostic imaging service:
(i) the providing practitioner is a consultant physician, or a specialist, in a particular specialty; and
(ii) the service was rendered by or on behalf of the providing practitioner in the course of the providing practitioner practising that specialty; and
(b) the service was rendered pursuant to a written request made by:
(i) another medical practitioner; or
(ii) subject to subsection (2), a dental practitioner; or
(iii) subject to subsection (3), a chiropractor; or
(iv) subject to subsection (3A), a physiotherapist; or
(v) subject to subsection (3B), a podiatrist; or
(vi) subject to subsection (3C), an osteopath; or
(vii) subject to subsection (3D), a participating midwife; or
(viii) subject to subsection (3E), a participating nurse practitioner;
who determined that the service was necessary and whose patient the person was.
Dental practitioners may only request certain services
(2) A request made by a dental practitioner, acting in his or her capacity as a dental practitioner, for an R - type diagnostic imaging service to be rendered is not effective for the purposes of subsection (1) unless it is a request for a service of a kind specified in regulations made for the purposes of this subsection.
Chiropractors may only request certain services
(3) A request made by a chiropractor, acting in his or her capacity as a chiropractor, for an R - type diagnostic imaging service to be rendered is not effective for the purposes of subsection (1) unless it is a request for a service of a kind specified in regulations made for the purposes of this subsection.
Physiotherapists may only request certain services
(3A) A request made by a physiotherapist, acting in his or her capacity as a physiotherapist, for an R - type diagnostic imaging service to be rendered is not effective for the purposes of subsection (1) unless it is a request for a service of a kind specified in regulations made for the purposes of this subsection.
Podiatrists may only request certain services
(3B) A request made by a podiatrist, acting in his or her capacity as a podiatrist, for an R - type diagnostic imaging service to be rendered is not effective for the purposes of subsection (1) unless it is a request for a service of a kind specified in regulations made for the purposes of this subsection.
Osteopaths may only request certain services
(3C) A request made by an osteopath, acting in his or her capacity as an osteopath, for an R - type diagnostic imaging service to be rendered is not effective for the purposes of subsection (1) unless it is a request for a service of a kind specified in regulations made for the purposes of this subsection.
Participating midwives may only request certain services
(3D) A request made by a participating midwife, acting in his or her capacity as a participating midwife, for an R - type diagnostic imaging service to be rendered is not effective for the purposes of subsection (1) unless it is a request for a service of a kind specified in regulations made for the purposes of this subsection.
Participating nurse practitioners may only request certain services
(3E) A request made by a participating nurse practitioner, acting in his or her capacity as a participating nurse practitioner, for an R - type diagnostic imaging service to be rendered is not effective for the purposes of subsection (1) unless it is a request for a service of a kind specified in regulations made for the purposes of this subsection.
Referral to specified practitioner not required
(4) For the purposes of subsection (1):
(a) the request need not be addressed to a particular practitioner; and
(b) where it is so addressed--the service need not be rendered by or on behalf of that practitioner.
Request may be for more than one service
(5) For the purposes of subsection (1), the request may be for the rendering of more than one R - type diagnostic imaging service, but, once one of the requested services has been rendered pursuant to the notice, any subsequent requested service is not taken to have been rendered pursuant to the notice unless it is so rendered within 7 days after the rendering of the first service.
Exemption--consultant physicians and specialists
(6) Subsection (1) does not apply if:
(a) the providing practitioner is a consultant physician, or a specialist, in a particular specialty (other than the specialty of diagnostic radiology); and
(b) the service was rendered by or on behalf of the providing practitioner in the course of the providing practitioner practising that specialty; and
(c) the providing practitioner determined that the service was necessary.
(7) Subsection (1) does not apply if:
(a) the service is not one for which there is a corresponding NR - type diagnostic imaging service; and
(b) the service was rendered within an area that is a remote area for the purposes of Division 2 of Part IIB; and
(c) the service was rendered during the period when a remote area exemption granted to the providing practitioner under section 23DX was in force; and
(d) if the remote area exemption in force in relation to the practitioner was restricted under subsection 23DY(1) to certain R - type diagnostic imaging services--the service is one of those R - type diagnostic imaging services; and
(i) the service was rendered before the end of one month (or such further period as the Chief Executive Medicare allows) after the commencement of this paragraph; or
(ii) the service was rendered after the end of that period at a time when the practitioner was registered as a participating practitioner in the Register of Participating Practitioners maintained under section 23DSC.
(8) Subsection (1) does not apply if the providing practitioner determines that, because the need for the service arose in an emergency, the service should be rendered as quickly as possible.
(9) Subsection (1) does not apply if:
(a) the person in relation to whom the service was rendered, or a person acting on that person's behalf, claimed that a medical practitioner, dental practitioner, chiropractor, physiotherapist, podiatrist, osteopath, participating midwife or participating nurse practitioner, had made a request for the service to be rendered, but that the request had been lost; and
(b) the providing practitioner, or an employee or agent of the providing practitioner, had sought and received from the medical practitioner, dental practitioner, chiropractor, physiotherapist, podiatrist, osteopath, participating midwife or participating nurse practitioner, (in this subsection called the requesting practitioner ) who was claimed to have made the request, or from an employee or agent of the requesting practitioner, confirmation that the request had been made; and
(c) if the requesting practitioner is a dental practitioner who made the request in his or her capacity as a dental practitioner--the request is not rendered ineffective by the operation of subsection (2); and
(d) if the requesting practitioner is a chiropractor who made the request in his or her capacity as a chiropractor--the request is not rendered ineffective by the operation of subsection (3); and
(e) if the requesting practitioner is a physiotherapist who made the request in his or her capacity as a physiotherapist--the request is not rendered ineffective by the operation of subsection (3A); and
(f) if the requesting practitioner is a podiatrist who made the request in his or her capacity as a podiatrist--the request is not rendered ineffective by the operation of subsection (3B); and
(g) if the requesting practitioner is an osteopath who made the request in his or her capacity as an osteopath--the request is not rendered ineffective by the operation of subsection (3C); and
(h) if the requesting practitioner is a participating midwife who made the request in his or her capacity as a participating midwife--the request is not rendered ineffective by the operation of subsection (3D); and
(i) if the requesting practitioner is a participating nurse practitioner who made the request in his or her capacity as a participating nurse practitioner--the request is not rendered ineffective by the operation of subsection (3E).
Exemption--additional services
(10) Subsection (1) does not apply if:
(a) the diagnostic imaging service (the additional service ) was rendered in relation to the person because the providing practitioner formed the opinion that the results obtained from the rendering of another diagnostic imaging service in relation to the person, pursuant to a subsection 16B(1) request, indicate that the additional service is necessary; and
(b) the additional service is a service in relation to which a medicare benefit is payable regardless of whether the service is rendered on the request of a specialist or a consultant physician.
Note: Medicare benefit is only payable on some diagnostic imaging services if they are rendered on the request of a specialist or consultant physician. The additional service must not be one of those services.
Exemption--substituted services
(10A) Subsection (1) does not apply if:
(a) the diagnostic imaging service (the substituted service ) was rendered in relation to the person in substitution for another service for which a subsection 16B(1) request has been made; and
(b) the substituted service was rendered because the providing practitioner formed the opinion that it would be more appropriate in the diagnosis of the person's condition to render the substituted service than the service requested; and
(c) the substituted service would be accepted by the general body of specialists or consultant physicians in the specialty practised by the providing practitioner as more appropriate in the diagnosis of the person's condition than the service requested; and
(d) before providing the substituted service, the providing practitioner has either consulted the person who made the subsection 16B(1) request, or taken all reasonable steps to consult that person; and
(e) the substituted service is a service in relation to which a medicare benefit is payable regardless of whether the service is rendered on the request of a specialist or a consultant physician.
Note: Medicare benefit is only payable on some diagnostic imaging services if they are rendered on the request of a specialist or consultant physician. The substituted service must not be one of those services.
Exemption--pre - existing diagnostic imaging practices
(11) Subsection (1) does not apply if:
(a) the service is a service of a kind specified in regulations made for the purposes of this subsection; and
(b) the service was rendered by or on behalf of the providing practitioner in the course of treating his or her own patient; and
(c) the providing practitioner determined that the service was necessary; and
(i) the service was rendered before the end of one month (or such further period as the Chief Executive Medicare allows) after the commencement of this paragraph; or
(ii) the service was rendered after the end of that period at a time when the practitioner was registered as a participating practitioner in the Register of Participating Practitioners maintained under section 23DSC; and
(e) during the period commencing on 17 October 1988 and ending on 16 October 1990, at least 50 services had been rendered by or on behalf of the providing practitioner, each being a service that:
(i) would have been an R - type diagnostic imaging service if it had been rendered after the commencement of this section; and
(ii) was rendered at the location at which the first - mentioned service was rendered; and
(iii) resulted in the payment of a medicare benefit.