Private health insurance clinical category definitions 1 March 2023

Standard clinical category definitions for private health insurance hospital policies, as of 9 December 2022 and effective 1 March 2023.


Private health insurance clinical category definitions 1 March 2023

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Health sector

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 ’MBS-XML-20230301’ released through MBS Online on 25 November 2022, effective 1 March 2023 and includes changes to the General Medical Services Table (GMST) and the Health Insurance Regulations 2018. This file also includes 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 the amendments made to the following categories:

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

New MBS Pathology Services Table (PST) items and Diagnostic Imaging Services Table (DIST) are automatically categorised as Support treatments so do not need to be listed in the clinical categories table. 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 for 1 March 2023 are intended to be made and published on the Federal Register of Legislation after commencement of 1 January MBS changes, and once the additional MBS XML for 1 March 2023 has been published. Formal notification will be provided via a Private Health Insurance Circular and on the Federal Register of Legislation following the finalisation of regulatory approval processes.

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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