Guideline for substantiating that a valid referral existed (from pathology or diagnostic imaging)
What you need to know
This guideline outlines what you can do to substantiate a service to be requested by another medical practitioner for Medicare Benefits Schedule (MBS) items 57521 and 65070.
This 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.
Read the Health Professional Guidelines about substantiating claims for Medicare compliance purposes before proceeding.
The Department of Health has the power under sections 23DK, 23DKA, 23DR and 23DS of the Health Insurance Act 1973 to require the production of documents relating to pathology and diagnostic imaging requests and services. These sections require a practitioner to maintain a record of the written request for a period of 2 years from the day on which the service was rendered.
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 pathology or diagnostic imaging request existed you could provide:
- a copy of the request and a copy of the report of the service - the copy of the request must clearly show the patient's name, the date of request and the name/s of the requesting practitioner, item number or description of the pathology or diagnostic imaging service requested
- an excerpt from the patient's clinical file maintained by the rendering practitioner - showing the name of the person who made the request, the date of service and a copy of the report of the service
- third party confirmation - if the rendering practitioner has failed to keep a request or a record of the service they may submit a copy of the request obtained from the original requesting practitioner
emergency under s16B(8) of the Health Insurance Act 1973 you could provide:
- an excerpt from the patient's record - maintained by the rendering practitioner showing the date of service, a copy of the report of the service and sufficient information to indicate the nature of the emergency.
To substantiate a diagnostic imaging service is provided but the request has been lost in the circumstances described under s16B(9) of the Health Insurance Act 1973 you may provide:
- an excerpt from the patient's record - maintained by the rendering practitioner showing the date of service, a copy of the report of the service and words indicating that the patient asserted that the request had been lost and that the providing practitioner had received confirmation from the requesting practitioner that the request had been made.
In most cases, a patient's clinical information will be the only way to confirm that a valid pathology or diagnostic imaging request existed, 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 provide the information to one of our medical advisers.
For information on what constitutes a valid request for a pathology service, see Regulation 4 of the Health Insurance (Pathology Services) Regulations 1989 on the Federal Register of Legislation website.
For information on what constitutes a valid request for a diagnostic imaging service, see Regulation 19 of the Health Insurance Regulations 1975 on the Federal Register of Legislation website
- What constitutes a referral? – see regulations 29-31 of the Health Insurance Regulations 1975
- MBS Online