Referrals

A medical referral helps specialist doctors provide care for your child.

If you wish to claim the advised Medicare Rebate, you must provide a referral to your specialist that is current and valid according to Medicare rules.

A valid and current Medicare referral to your specialist must be on file before the commencement of the appointment to enable a Medicare rebate claim.

It is the responsibility of patients or their parents to ensure we have this referral on file.

We routinely provide information about 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.

REFERRAL STATUS, EXPIRY AND REBATES:

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 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 DATEl:

• 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 referral.Referral Term: 

• The Referral Term STARTS on the date of your first appointment under that referral. The START DATE is usually after the ISSUE DATE, when your GP wrote the referral.

Our Booking Email 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 (this may be the actual start date or an expected/upcoming Start Date)
  The duration of the referral is 12  months  

• This tells you that the referral will expire 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 the 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)

    • The specialist’s referral expires on 29 June 2019 (not valid on 30 June)

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 are tricky. Your GP may intend their referral to have an indefinite term up to age 18 or up to the time when a particular medical concern has been resolved. 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.

Medicare recognised referrers? Medicare only recognises referrals from Registered Medical Practitioners. Letters from your Clinical Psychologist, Occupational Therapist or other Allied Health providers often have great 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.

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.

Backdating or seeking a referral after your appointment?

Medicare does not permit GPs or Specialists to backdate any referral or to request a backdated referral.

Nor does Medicare permit the lodgement of a rebate claim linked to a backdated or otherwise invalid referral.

Sometimes an existing valid referral has been left at home, or the GP has forgotten to fax a previously written referral in time. In this case, families may seek to provide this referral as soon as possible and no later than 4 pm on the same day as the appointment. Whether the referral is recorded for Medicare purposes will be at the discretion of Practice Management in light of the circumstances, the content of the referral, the apparent time and date it was provided and Medicare rules. A referral supplied to us under these circumstances would not be considered valid if the date of issue is the same as the date of the specialist appointment.

Even if the referral is found to be valid in these situations, the practice cannot guarantee that the referral will be filed and used for claim lodgement due to the complexity and nature of the daily procedures involved. Where a valid referral is not provided, our policy requires that immediately following an appointment, the service is invoiced and then claimed against the applicable item- in this case, an “un-referred item”. It is not possible to guarantee that this can be changed later in the day.

To avoid difficulties 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 and preferably at the time of booking.

If your child does not have a current referral, a smaller rebate may be claimed in most circumstances.

THE REFERRAL LETTER-KEY REQUIREMENTS:

• Addressed to a provider in a specific person or to “ Paediatrician” or “Paediatric Neurologist, Occupational Therapist, etc.

  • You can provide and use a referral to a specific person with another doctor in the same specialty.

• Show the name of the referring doctor, their practice address and provider number

• provide a clinical reason for the referral

• be dated and signed by the referring doctor

• have an issue date and time no later than the day and start time of the appointment,

• be provided before the start time of the appointment.

Referrals to allow Medicare Rebates for certain Allied Health Services

Allied health appointments are only eligible for Medicare rebates if you have one of the following special referrals.

Referrals to 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 include 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 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 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.