Private health insurance clinical category definitions 1 August 2022

Standard clinical category definitions for private health insurance hospital policies, effective 1 August 2022.


Clinical categories for private health insurance hospital product tier arrangements.

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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 Benefit Schedule (MBS) items that should be covered. The list of items is derived from the ’XML-220719-MBS’ released on 18 July 2022 and ‘XML-220801-MBS’ released on 20 July 2022.

The 18 July 2022 XML file includes two new temporary telehealth phone services for General Practitioners (93716) and Other Medical Practitioners (93717) for assessing a patient’s eligibility to receive a prescription for a COVID-19 oral anti-viral medication. The new temporary telehealth phone consultation MBS items have nil impact for private health insurance minimum benefit assignment.

The 20 July 2022 XML incorporates 1 August 2022 changes which include, one new temporary substitute positron emission tomography (PET) item for use during gallium-67 (Ga‑67) supply disruptions (61527), clarification of the co-claiming arrangements for colorectal surgery item 32006, increased fee for gynaecological surgery item 35723, minor amendments to the descriptors for seven other gynaecological services and other minor administrative changes.

There are no changes to the clinical categories table as MBS item 61527 is automatically categorised in the Support treatments and the other changes have no impact on clinical category assignment.

The assignment of MBS items by clinical category reflects the PHI rules, accessible on the Federal Register of Legislation.

For older versions of this publication, review the Private health insurance clinical category and procedure type collection, or visit the National Library's web archive.

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