Private health insurance clinical category definitions 1 March 2023

Standard clinical category definitions for private health insurance hospital policies, as of 23 February 2023 and effective 1 March 2023.


Private health insurance clinical category definitions 1 March 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 Benefit Schedule (MBS) items that should be covered. This list of items is derived from the ‘MBS-XML-20230301.V2 (XML 7816 KB)’ released on 6 February 2023 through MBS Online and effective 1 March 2023. It replaces an interim file based on the MBS XML Data File release of 25 November 2022. The current documents reflect changes made to items of the MBS General Medical Services Table (GMST), Pathology Services Table (PST), Diagnostic Imaging Services Tables (DIST) and the Health Insurance Regulations 2018. These files also include changes to various instruments made under subsection 3C(1) of the Health Insurance Act 1973.

The MBS Online March 2023 News provides a summary of MBS changes for 1 March 2023. Key MBS item changes for private health include:

  • Thoracic surgery item changes
  • Otolaryngology, Head and Neck Surgery item changes
  • new MBS item (63564) for a whole body (W/B) MRI scan to enable the detection of cancer in individuals with germline pathogenic TP53 variants
  • amendments to attendance services for complex neurodevelopmental disorders and disabilities
  • other minor technical and administrative amendments.

The clinical category definitions reflect amendments made to the following categories:

  • Hospital psychiatric services
  • Brain and nervous system
  • Digestive system
  • Ear, nose and throat
  • Eye (not cataracts)
  • Gastrointestinal endoscopy
  • Heart and vascular system
  • Implantation of hearing devices
  • Lung and chest
  • Plastic and reconstructive surgery (medically necessary)

New PST items and 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 MBS items.

The assignment of MBS items by clinical category reflects the PHI rules. The PHI Rules will be published on the Federal Register of Legislation and formal notification will be provided via a Private Health Insurance Circular.

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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