Downloads
Private Health Insurance clinical category definitions 1 March 2025
We aim to provide documents in an accessible format. If you're having problems using a document with your accessibility tools, please contact us for help.
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-20250301 (XML 7958 KB)’ released on 12 February 2025 through MBS Online and effective 1 March 2025. The document reflects consequential Private Health Insurance (PHI) changes to the General Medical Services Table (GMST), Pathology Services Table (PST) 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 2025 News:
- General medical services
- Pathology services
- Diagnostic Imaging services
- Other administrative and machinery changes.
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
- Pregnancy and Birth
- 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.
The assignment of MBS items by clinical category reflects the Private Health Insurance Legislation Amendment Rules for 1 March 2025 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.
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.