[pic] Health Insurance (Pathology Services) Regulations 1989 Statutory Rules 1989 No. 75 as amended made under the Health Insurance Act 1973 This compilation was prepared on 21 October 2006 taking into account amendments up to SLI 2006 No. 273 The text of any of those amendments not in force on that date is appended in the Notes section Prepared by the Office of Legislative Drafting and Publishing, Attorney-General's Department, Canberra Contents 1 Name of Regulations [see Note 1] 3 2 Repeal of former Health Insurance (Pathology Services) Regulations 3 3 Interpretation 3 4 Requests for pathology services 3 5 Termination of undertaking - sections 23DE and 23DH of the Act 8 Notes 9 1 Name of Regulations [see Note 1] These Regulations are the Health Insurance (Pathology Services) Regulations 1989. 2 Repeal of former Health Insurance (Pathology Services) Regulations Statutory Rules 1977 No. 127, 1979 No. 66, 1983 Nos. 254 and 256 and 1984 No. 6 are repealed. 3 Interpretation In these Regulations, unless the contrary intention appears: the Act means the Health Insurance Act 1973. 4 Requests for pathology services (1) In this regulation, unless the contrary intention appears: provider number, in relation to a practitioner or an approved pathology practitioner, has the same meaning as in the Health Insurance Regulations. relevant address, in relation to a treating practitioner or an approved pathology practitioner, who makes a request, means: (a) where the request is made from a place of practice of the treating practitioner or approved pathology practitioner - the address of that place; or (b) where paragraph (a) does not apply - the address of any place of practice of the treating practitioner or approved pathology practitioner. request means a request for a pathology service (other than a pathologist-determinable service to which subsection 16A (6) of the Act applies) made in accordance with subsection 16A (3) of the Act. treating practitioner has the same meaning as in section 16A of the Act. (2) A request shall, subject to subregulation (8), contain the particulars required by subregulations (3), (4), (5), (6) and (7) to be included in a request. Note A request in respect of a person who is a private hospital patient may also contain information about the person's private health insurance - see subregulation (5A). (3) A request shall include the following particulars in respect of the treating practitioner, or approved pathology practitioner, who makes the request (in this subregulation called the requesting practitioner): (a) the surname and the initials of the given names of the requesting practitioner or, where the requesting practitioner is a member of a group of practitioners, being practitioners at least one other of whom has the same surname and the same initials as the requesting practitioner, the surname and such of the given names of the requesting practitioner as would distinguish him or her from each of those other practitioners in that group; (b) the relevant address; and (c) the provider number that relates to the place of practice of the requesting practitioner at that address. (4) A request shall include the following particulars in respect of the person to whom the request is made: (a) where the person is an approved pathology practitioner: (i) the surname and the initials of the given names of the approved pathology practitioner or, where the approved pathology practitioner is a member of a group of practitioners, being practitioners at least one other of whom has the same surname and the same initials as the approved pathology practitioner, the surname and such of the given names of the approved pathology practitioner as would distinguish him or her from each of those other practitioners in that group; and (ii) the address of a place of practice of the approved pathology practitioner; (b) where the person is an approved pathology authority: (i) the full name of the approved pathology authority; and (ii) the address of a place of practice of the approved pathology authority. (5) A request shall include the following particulars in respect of the person in relation to whom the service is requested: (a) the name of the person; (b) the address of the person; (c) whether the person is: (i) a public patient in a recognized hospital; (ii) a private patient in a recognized hospital; (iii) a private patient in a private hospital; or (iv) a private patient in a day hospital facility; (d) whether the request is made in the course of the provision in relation to the person of an out-patient service at a recognized hospital. (5A) A request for a service in respect of a person described in subparagraph (5) (c) (ii), (iii) or (iv) may include the following particulars for the purpose of a private health insurance claim in relation to the service, if the person consents to the inclusion of those particulars for that purpose: (a) the name of the private health insurance fund of which the person is a member; (b) the membership number or other unique identifier allocated to the person by the fund. (5B) Failure by a person to consent to the inclusion of the particulars mentioned in subregulation (5A) in a request for a service in respect of the person does not affect any entitlement the person may have to a medicare benefit, or a benefit payable by a private health insurance fund, in respect of the service. (6) A request shall include the following particulars in respect of the service, or each service, requested: (a) a description of the service in terms or symbols that: (i) would be generally understood by medical practitioners; and (ii) are sufficient to identify the service for the purpose of ascertaining the item (if any) in which that service is specified; (b) the date on which the service was determined to be necessary; (c) whether the service is a pathology service in relation to a bodily specimen obtained from a person while the person was an in-patient of a hospital or day hospital facility that is to be performed after the person has ceased to be such a patient; (d) if the requesting practitioner forms an opinion in accordance with subregulation (6B) that the requested pathology service is a hospital-related service within the meaning of subregulation (6A) - the letter A. (6A) In paragraph (6) (d): hospital-related service means: (a) a pathology service requested in relation to a person for a condition in relation to which the person will, or is likely to, receive treatment in a hospital or day hospital facility within 4 weeks of the service being provided, for example, tests performed prior to a person undergoing surgery in a hospital; or (b) a pathology service requested in relation to a person for a condition in relation to which the person had received treatment in a hospital or day hospital facility in the 4 weeks immediately before provision of the service; or (c) a pathology service requested in relation to a person, the request for which is made in connection with a condition in relation to which, immediately before receiving the service resulting in the making of the request, the person had presented for treatment to a recognised hospital and was referred or directed to the practitioner who provided that service; or (d) a pathology service requested in connection with the provision of a professional service at a recognised hospital in relation to a person who is not admitted to that hospital in connection with that service. (6B) In forming the opinion mentioned in paragraph (6) (d), the practitioner must have regard to the nature of the requested pathology service and all the circumstances in which the service is to be provided including, but not limited to: (a) the results of any examination by the practitioner of the person in relation to whom the service is to be provided; and (b) the results of any tests in relation to the person conducted by, or made available to, the practitioner; and (c) the history and any other information given to the practitioner by the person; and (d) any letter, form or document given to the practitioner in connection with the provision by the practitioner of a professional service to the person. (7) Where a request for a service is made to an approved pathology practitioner or approved pathology authority by an approved pathology practitioner (in this subregulation called the referring pathologist) to whom the treating practitioner has made a request for the service, the first-mentioned request shall include the following particulars, namely, the name, address and provider number of the treating practitioner as included in the request made by him or her to the referring pathologist. (8) Where: (a) a practitioner determines that a service is, or services are, necessary in relation to a person; (b) the practitioner makes a request to an approved pathology practitioner in relation to that service or those services; and (c) the approved pathology practitioner referred to in paragraph (b) makes a request to another approved pathology practitioner or to an approved pathology authority in relation to that service or those services; the request referred to in paragraph (c) (in this subregulation referred to as the first-mentioned request), when made, or confirmed, in writing, shall not be required to include the particulars referred to in subregulations (5), (6) and (7) if: (d) the request referred to in paragraph (b) relates to the service, or services, to which the first-mentioned request relates and no other service; and (e) the document in writing containing or confirming the request referred to in paragraph (b) is annexed to the document containing or confirming the first-mentioned request. 5 Termination of undertaking - sections 23DE and 23DH of the Act For the purposes of sections 23DE and 23DH of the Act, a notice of termination shall be given by addressing it, and sending it by pre-paid post, to the Minister at the office of Medicare Australia, P.O. Box 1001, Tuggeranong, A.C.T. 2901. Notes to the Health Insurance (Pathology Services) Regulations 1989 Note 1 The Health Insurance (Pathology Services) Regulations 1989 (in force under the Health Insurance Act 1973) as shown in this compilation comprise Statutory Rules 1989 No. 75 amended as indicated in the Tables below. Under the Legislative Instruments Act 2003, which came into force on 1 January 2005, it is a requirement for all non-exempt legislative instruments to be registered on the Federal Register of Legislative Instruments. From 1 January 2005 the Statutory Rules series ceased to exist and was replaced with Select Legislative Instruments (SLI series). Numbering conventions remain the same, ie Year and Number. Table of Instruments |Year and |Date of |Date of |Applicatio| |number |notification|commencement |n, saving | | | | |or | | |in Gazette | |transition| | |or FRLI | |al | | |registration| |provisions| |1989 No. 75 |4 May 1989 |4 May 1989 | | |1996 No. 236|30 Oct 1996 |1 Nov 1996 |- | |2005 No. 100|27 May 2005 |28 May 2005 |- | | |(see | | | | |F2005L01221)| | | |2005 No. 207|19 Sept 2005|1 Oct 2005 (see |- | | |(see |r. 2) | | | |F2005L02673)| | | |2006 No. 273|20 Oct 2006 |21 Oct 2006 |- | | |(see | | | | |F2006L03306)| | | Table of Amendments |ad. = added or inserted am. = amended rep. = | |repealed rs. = repealed and substituted | |Provision affected|How affected | |R. 1 |rs. 2005 No. 100 | |R. 4 |am. 1996 No. 236; 2005 No. 100; 2006 | | |No. 273 | |Note to r. 4 (2) |ad. 2005 No. 100 | |R. 5 |am. 2005 No. 207 |