Health professional guidelines - Information

The health professional guidelines have been developed in conjunction with peak bodies. It is important that you read the general information below. If you require information on the types of substantiating documents required for specific services please refer to the relevant guideline.

Page last updated: 12 January 2016

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Formal notice to produce documents

Under section 129AAD of the Health Insurance Act 1973, if we have reasonable concern that you've been paid a benefit that exceeds the amount you should have been paid, we can ask you to substantiate your claims.
A formal notice to produce documents will be issued if you don't provide substantiating documents for Medicare compliance audit or review purposes.

Obligations under the under the Public Governance, Performance and Accountability Act 2013

Under the Public Governance, Performance and Accountability Act 2013, we must recover money owed to the Australian Government. If you incorrectly claim a Medicare benefit or receive an incorrect payment, you’ll be asked torepay the money you received.

Voluntary acknowledgement

If you think you may have received an incorrect Medicare benefit or payment, you can voluntarily tell us. If you voluntarily acknowledge an incorrectly claimed benefit, you may be entitled to a reduced administrative penalty.
To do this you must complete the Voluntary acknowledgement of incorrect payments form.

Review of decision

In some circumstances you can apply to review the decision of a Medicare compliance audit or review if you are advised to repay an incorrectly claimed benefit or payment.
You can do this by completing the Application to Review Compliance Audit Decision form.
You must apply to review a decision within 28 days of receiving notice that an amount is owing.

Record keeping

If you provide or initiate a service where a Medicare benefit is payable you should make sure you keep adequate and up to date records.
Records should:
    • clearly identify the name of the patient
    • have a separate entry each time the patient has attended a service
    • include the date the service was provided or initiated
    • contain enough information to explain the type of service provided
    • be clear enough so another practitioner, relying on the record, could effectively undertake the patient's ongoing care
    • be up to date, making sure it's completed at the time the service was provided or as soon as possible afterwards, and
    • be in either paper or electronic form
For more information about record keeping, go to the Administrative Record Keeping Guidelines or contact your relevant professional body.

Additional resources

Guidelines for substantiating claims for Medicare compliance purposes

If your require information on the types of substantiating documents required for specific services please refer to the relevant guideline. 

Other

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