Guideline for substantiating that a valid referral existed (from specialist or consultant physician)
What you need to know
This guideline outlines what you can do to substantiate Medicare Benefits Schedule (MBS) items 104, 105, 110, 116, 122, 132, 133, 135, 141, 143, 145 and 147 that require receipt of a valid referral before the service is provided.
The guideline is not exhaustive and you can respond to a Medicare compliance audit or review using any documents you think substantiate the concern raised.
However, we may determine more information is needed and request additional documentation to substantiate services you have claimed.
Note: the Department of Health has the power under section 20BA of the Health Insurance Act 1973 to require the production of referrals.
Section 20BA(1)(d) requires a specialist or consultant physician to whom a patient has been referred to retain the referral for a period of 2 years from the day on which the service was rendered.
Read the Health Professional Guidelines about substantiating claims for Medicare compliance purposes before proceeding.
Documents you may use to substantiate a claim
Any document you give us should be created during or as soon after the treatment occurred. It should include the patient's name and the date the treatment was provided.
To substantiate that a valid referral existed before the service was provided you could provide:
- a copy of the referral - clearly showing the patient's name, the date of referral and the name/s of the referring practitioner, specialist or consultant physician
- if the referring practitioner is a specialist or consultant physician, a copy of the referral, as outlined above, and either
- the name of the general practitioner, participating midwife or participating nurse practitioner nominated by the patient
- a statement to the effect that the patient is unwilling or unable to nominate a general practitioner, participating midwife or participating nurse practitioner
- an excerpt from the patient's clinical file - noting a referral was viewed or received may generally satisfy this request if it shows the person who made the referral and the date of service
- third party corroboration - if a specialist or consultant physician has failed to keep a record of the referral they may seek a copy from the original referring practitioner.
To substantiate that a service is provided by a specialist or consultant physician in an emergency without a referral under Regulation 30 of the Health Insurance Regulations 1975 you may provide an excerpt from the patient's clinical record showing:
- the patient's name
- the date of the service
- sufficient information to indicate the nature of the emergency.
In most cases, a patient's clinical information will be the only way to confirm that a valid referral existed before the service was provided, and to substantiate you received the correct Medicare benefit.
If you need to use a patient's clinical information you can censor any details that aren't relevant. You can also choose to provide the information to one of our medical advisers.
- What constitutes a referral? – see regulations 29-31 of the Health Insurance Regulations 1975
- MBS Online