Guideline for substantiating valid individual Allied Health Services were provided (for allied health professionals)

Page last updated: 23 November 2016

What you need to know

This guideline outlines what you can do to substantiate valid individual Allied Health services were provided for Medicare Benefits Schedule (MBS) items 10950 to 10970.

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 that valid individual allied health services were provided, you may provide:
    • a copy or excerpt of a referral form from a medical practitioner - that has been issued by the Department of Health, or a referral form that contains all the components of the form issued by the Department. The form must include the patient details, the referring medical practitioner details and should be dated and signed by the medical practitioner
    • a copy or excerpt of a report written to the referring general practitioner - written for the first and/or last service provided under the referral, and clearly showing the name of the patient, the name of the referring GP and the date of the report
    • an excerpt/s from the patient's clinical file - clearly showing the patient's name and the date of service
Note: schedule 2, Part 1 of the Health Insurance (Allied Health Services) Determination 2014, as reflected in MBS item descriptors and explanatory notes M3.1-3.5, outline all required components of MBS items 10950 to 10970.

In most cases, a patient's clinical information will be the only way to confirm that the patient attended the 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.

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