Guideline for substantiating that a patient attended a service

Page last updated: 14 January 2016

What you need to know

This guideline outlines what you can do to substantiate that a patient attended a service and relates to Medicare Benefits Schedule (MBS) items such as 23, 36, 104, 5020, 10960 and 8553 that require the patient to be present.

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.

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 have been created during or as soon as practicable after the treatment occurred. It should include the patient's name and the date the treatment was provided.

To substantiate in the first instance that a patient attended a service you may provide:
    • a payment receipt - any type of receipt containing the patient's name or signature to confirm that the patient paid for the service
    • a daybook or other note created during or as soon as practicable after patient attendance - any record kept by a practitioner, third party or practice that is made at the time of a patient attendance indicating the name of the patient and the date of service
    • any document created during the attendance - that includes the patient's name, the date of service and a comment on the service. For example, a copy of a referral, request, medical certificate or other document that contains the patient's name and the date of service
    • an excerpt from the patient's clinical file - clearly showing the patient's name and the date of service and sufficient information to verify the attendance of the patient. This may include history or examination findings entered into the clinical file during or as soon as practicable after the provision of the service
In most cases, a patient's clinical information will be the only way to confirm that the patient attended a service, 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.

Resources