Private Health Insurance clinical categories definitions – 1 November 2023
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Definitions of the clinical categories for hospital treatment policies as found in the Private Health Insurance (Complying Product) Rules 2015.
The clinical categories include an indicative list of Medicare Benefits Schedule (MBS) items that should be covered. This list of items is derived from the MBS XML Data file ‘MBS-XML-20231101 (XML 8001 KB)’ released on 16 October 2023 through MBS Online and effective 1 November 2023. The current documents reflect consequential PHI changes made as a result of changes to the items the MBS General Medical Services Table, Pathology Services Table (PST), the Health Insurance Regulations 2018 and an instrument made under subsection 3C(1) of the Health Insurance Act 1973.
Key MBS item changes of potential interest to stakeholders are summarised below, and outlined in the MBS Online November 2023 News:
- cardiac services changes: Leadless Pacemaker, see New and amended items for leadless permanent cardiac pacemaker
- pathology services including multiple genetic tests for diagnosis of various conditions
- skin services
- optometry services.
Further information including fact sheets and quick reference guides is at MBS Online.
The clinical category definitions reflect amendments made to the MBS items assigned to the following categories:
- heart and vascular system
- lists of Support treatments and Common treatments.
New PST items and Diagnostic Imaging Services Table (DIST) items are automatically categorised as Support treatments so do not need to be listed in the clinical categories tables in the PHI Rules. All Support items are identified in the Private Health Insurance classification of 1 November 2023.
The assignment of MBS items by clinical category reflects the Private Health Insurance Legislation Amendment Rules for 1 November 2023 which will be published on the Federal Register of Legislation following the finalisation of regulatory approval processes. Details of the changes will be available in the Explanatory Statement that will accompany the Amendment Rules.
Formal notification of the Amendment Rules registration from the Department of Health and Aged Care will be via Private Health Insurance Circular.
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Receive notification of updates to PHI Spreadsheets, and other PHI information, by emailing PHI@health.gov.au requesting subscription to the email newsletter.
For previous versions of PHI Spreadsheet publications, review the Private health insurance clinical category and procedure type collection, or visit the National Library's web archive.