Private Health Insurance clinical category definitions – 1 March 2024

Standard clinical category definitions for private health insurance hospital policies, released on 9 February 2024 and effective at 1 March 2024.


Private Health Insurance clinical category definitions – 1 March 2024

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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-20240301 (XML 8002 KB)’ released on 2 February 2024 through MBS Online and effective 1 March 2024. The current documents reflect consequential PHI changes to the General Medical Services Table (GMST) and the Diagnostic Imaging Services Table (DIST). 

Key MBS item changes of potential interest to stakeholders are summarised below, and outlined in the MBS Online - March 2024 News:

  • Orthopaedic services item changes will include 30 new items and 86 amended items.
  • Psychiatry services item changes which will insert, amend and delete items to provide more flexible arrangements, strengthen the intent of the services and clarify and remove obsolete terms from items.
  • Plastic and reconstructive surgery item changes include 14 amend items to ensure the appropriate provision of the specified services in hospital settings only. 
  • Cleft and Craniofacial Services item changes related to cleft dental and modernise the clinical practice for treating patients with cleft and craniofacial conditions.
  • Other changes to the General Medical Services Table and Diagnostic Imaging Services Table

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:

  • Bone, joint and muscle
  • Brain and nervous system
  • Breast surgery (medically necessary)
  • Dental surgery
  • Gastrointestinal endoscopy
  • Hospital psychiatric services
  • Joint reconstructions
  • Joint replacements
  • Male reproductive system
  • Plastic and reconstructive surgery (medically necessary)
  • lists of Support treatments and Common treatments

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 1 March 2024.

The assignment of MBS items by clinical category reflects the Private Health Insurance Legislation Amendment Rules for 1 March 2024 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.

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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

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