Health Insurance (Professional Services Review Scheme) Regulations 2019

law://au/li/2019/f2019l00180@2026-11-13

Contents

Part 1 · Preliminary

1Name#

This instrument is the Health Insurance (Professional Services Review Scheme) Regulations 2019.

3Authority#

This instrument is made under the Health Insurance Act 1973.

5Definitions#

Note: A number of expressions used in this instrument are defined in the Act, including the following:

(a) general medical services table;

(b) general practitioner;

(d) medical practitioner;

(e) professional service.

In this instrument:

Act means the Health Insurance Act 1973.

practitioner has the same meaning as in Part VAA of the Act.

relevant DVA law has the same meaning as in Part VAA of the Act.

relevant phone service: see section 5B.

relevant service: see section 5A.

service has the same meaning as in Part VAA of the Act.

5AMeaning of relevant service#

(1)A relevant service is:

(a)a service specified in any of the items of the general medical services table covered by subsection (2); or

(b)a service:

(i)to which paragraph (c) or (d) of the definition of service in subsection 81(1) of the Act applies; and

(ii)that is of a kind that, if the service had not been rendered in connection with the provision of treatment under a relevant DVA law, medicare benefit would have been payable in respect of the service for a service specified in any of the items of the general medical services table covered by subsection (2).

(2)This subsection covers the following items of the general medical services table:

(a)an item in Group A1, A2, A5, A6, A7, A9, A11, A13, A14, A15, A17, A20, A21, A22, A23, A27, A35 or A48;

(b)an item in Subgroup 1 or 4 of Group A36;

(c)an item in any of the following Subgroups of Group A40:

(i)Subgroup 1;

(ii)Subgroup 2;

(iii)Subgroup 3;

(iv)Subgroup 10;

(v)Subgroup 11;

(vi)Subgroup 13;

(vii)Subgroup 15;

(viii)Subgroup 16;

(ix)Subgroup 19;

(x)Subgroup 21;

(xi)Subgroup 27;

(xii)Subgroup 28;

(xiii)Subgroup 29;

(xiv)Subgroup 39;

(xv)Subgroup 40;

(d)an item listed in the following table.

Relevant services—individual items
Item	Column 1Group or Subgroup	Column 2Items of the general medical services table
1	Group A29	139
2	Group A36	90264, 90265
3	Subgroup 17 of Group A40	92142
4	Subgroup 25 of Group A40	92170, 92171
5	Subgroup 26 of Group A40	92176, 92177

Note: Some services are specified in items set out in determinations under subsection 3C(1) of the Act.

5BMeaning of relevant phone service#

(1)A relevant phone service is:

(a)a service specified in any of the items of the general medical services table covered by subsection (2); or

(b)a service:

(i)to which paragraph (c) or (d) of the definition of service in subsection 81(1) of the Act applies; and

(2)This subsection covers the following items of the general medical services table:

(a)an item in any of the following Subgroups of Group A40:

(i)Subgroup 2;

(ii)Subgroup 8;

(iii)Subgroup 10;

(iv)Subgroup 16;

(v)Subgroup 28;

(vi)Subgroup 40;

(b)item 92176 or 92177 in Subgroup 26 of Group A40.

Note: Some services are specified in items set out in determinations under subsection 3C(1) of the Act.

Part 2 · Prescribed matters for definitions

6Standards for adequate and contemporaneous records#

For the purposes of the definition of adequate and contemporaneous records in subsection 81(1) of the Act, the standards for a record of the rendering or initiation of services to a patient by a practitioner are that:

(a)the record must include the name of the patient; and

(b)the record must contain a separate entry for each attendance by the patient for a service; and

(c)each separate entry for a service must:

(i)include the date on which the service was rendered or initiated; and

(ii)provide sufficient clinical information to explain the service; and

(iii)be completed at the time, or as soon as practicable after, the service was rendered or initiated; and

(d)the record must be sufficiently comprehensible to enable another practitioner to effectively undertake the patient’s ongoing care in reliance on the record.

7Exceptional circumstances in relation to inappropriate practice#

For the purposes of subsection 82(1D) of the Act, each of the following circumstances are exceptional circumstances for a particular day for a practitioner:

(a)an unusual occurrence causing an unusual level of need for relevant services on the day;

(b)an absence, on the day, of other medical services for the practitioner’s patients, having regard to:

(i)the location of the practitioner’s practice; and

(ii)the characteristics of the practitioner’s patients.

8Circumstances for medical practitioners for prescribed pattern of services#

For the purposes of section 82A of the Act, circumstances in which services rendered or initiated by a medical practitioner constitute a prescribed pattern of services are that:

(a)the medical practitioner renders or initiates 80 or more relevant services on each of 20 or more days in a 12 month period; or

(b)the medical practitioner renders or initiates 30 or more relevant phone services on each of 20 or more days in a 12 month period.

Part 3 · Professional Services Review Committees

9Allowances for witnesses at hearings#

(1)This section is made for the purposes of subsection 106C(1) of the Act and deals with allowances for expenses in respect of attendance by a person summoned to appear as a witness at a hearing before a Professional Services Review Committee.

Kinds of allowances

(2)The allowances for a witness are the following:

(a)attendance allowance in accordance with subsection (3) or (4) as applicable;

(b)travel allowance in accordance with subsection (5).

Amount of attendance allowance

(3)For a witness attending because of the witness’ professional, scientific or other special skill or knowledge, the amount of attendance allowance is equal to the witness’ actual fees for preparing to give evidence and of attending to give evidence.

(4)For a witness other than a witness mentioned in subsection (3), the amount of attendance allowance is equal to:

(a)if the witness is paid by salary—any salary actually lost because of the attendance; or

(b)if the witness is paid by wages—any wages actually lost because of the attendance; or

(c)if the witness is paid by fees—any fees actually lost because of the attendance;

up to a maximum of $527 per day.

Amount of travel allowance

(5)The amount of travel allowance for a witness is a reasonable amount, determined in relation to the witness by the Professional Services Review Committee, for:

(a)transport to and from the hearing; and

(b)if the witness is required to be absent overnight from the witness’ usual place of residence—meals and accommodation during the absence.

Part 4 · Referral of professional issues to regulatory and other bodies

10Specified persons and bodies—significant threat to life or health#

(1)For the purposes of paragraph 106XA(4)(a) of the Act, this section specifies persons and bodies for persons who render professional services.

General practitioners

(2)The following persons and bodies are specified for a person who renders professional services who is a general practitioner:

(a)the Australian College of Rural and Remote Medicine;

(b)Australian General Practice Accreditation Limited;

(c)the Australian Health Practitioner Regulation Agency;

(d)the Health Care Complaints Commission of New South Wales;

(e)the Health Ombudsman of Queensland;

(f)the Medical Board of Australia;

(g)the Medical Council of New South Wales;

(h)Quality Practice Accreditation Pty Ltd;

(i)the Royal Australian College of General Practitioners.

Persons who are not general practitioners

(3)The following persons and bodies are specified for a person who renders professional services who is not a general practitioner:

(a)the Aboriginal and Torres Strait Islander Health Practice Board of Australia;

(b)the Australian Health Practitioner Regulation Agency;

(c)the Chinese Medicine Board of Australia;

(d)the Chiropractic Board of Australia;

(e)the Dental Board of Australia;

(f)the Department;

(g)the Health Ombudsman of Queensland;

(h)the Human Services Department;

(i)the Medical Board of Australia;

(j)the Medical Council of New South Wales;

(k)the Medical Radiation Practice Board of Australia;

(l)the Nursing and Midwifery Board of Australia;

(m)the Optometry Board of Australia;

(n)the Osteopathy Board of Australia;

(o)the Paramedicine Board of Australia;

(p)the Pharmacy Board of Australia;

(q)the Physiotherapy Board of Australia;

(r)the Podiatry Board of Australia;

(s)the Psychology Board of Australia.

11Specified bodies—non-compliance with professional standards#

General practitioners

(1)For the purposes of subsection 106XB(3) of the Act, a body is specified in relation to a practitioner who is a general practitioner if:

(a)the body:

(i)is specified in subsection 10(2) of this instrument; and

(ii)has the power to take action against the practitioner if the practitioner has failed to comply with professional standards; or

(b)the body has the function of assisting a person who:

(i)is specified in subsection 10(2) of this instrument; and

(ii)has the power to take action against the practitioner if the practitioner has failed to comply with professional standards.

Practitioners who are not general practitioners

(2)For the purposes of subsection 106XB(3) of the Act, a body is specified in relation to a practitioner who is not a general practitioner if:

(a)the body:

(i)is specified in subsection 10(3) of this instrument; and

(ii)has the power to take action against the practitioner if the practitioner has failed to comply with professional standards; or

(b)the body has the function of assisting a person who:

(i)is specified in subsection 10(3) of this instrument; and

(ii)has the power to take action against the practitioner if the practitioner has failed to comply with professional standards.

Part 5 · Transitional provisions

12Amendments made by the Health Insurance (Professional Services Review Scheme) Amendment (2022 Measures No. 4) Regulations2022#

Paragraph 8(b) applies in relation to relevant phone services rendered on or after 1 October 2022.

13Amendments made by the Health Insurance (Professional Services Review Scheme) Amendment (Prescribed Pattern of Services) Regulations2026#

Paragraphs 5A(1)(b) and 5B(1)(b) of this instrument, as inserted by Schedule 1 to the Health Insurance (Professional Services Review Scheme) Amendment (Prescribed Pattern of Services) Regulations 2026, apply in relation to a service rendered on or after the commencement of this section.

Sourced from the Federal Register of Legislation at legislation.gov.au, © Commonwealth of Australia, licensed under CC BY 4.0. Compilations may have been reformatted.

1Name#

3Authority#

5Definitions#

5AMeaning of relevant service#

5BMeaning of relevant phone service#

6Standards for adequate and contemporaneous records#

7Exceptional circumstances in relation to inappropriate practice#

8Circumstances for medical practitioners for prescribed pattern of services#

9Allowances for witnesses at hearings#

10Specified persons and bodies—significant threat to life or health#

11Specified bodies—non-compliance with professional standards#

12Amendments made by the Health Insurance (Professional Services Review Scheme) Amendment (2022 Measures No. 4) Regulations2022#

13Amendments made by the Health Insurance (Professional Services Review Scheme) Amendment (Prescribed Pattern of Services) Regulations2026#

Defined terms · 6

Connections

History · 1 version

Key facts

1Name#

3Authority#

5Definitions#

5AMeaning of relevant service#

5BMeaning of relevant phone service#

6Standards for adequate and contemporaneous records#

7Exceptional circumstances in relation to inappropriate practice#

8Circumstances for medical practitioners for prescribed pattern of services#

9Allowances for witnesses at hearings#

10Specified persons and bodies—significant threat to life or health#

11Specified bodies—non-compliance with professional standards#

12Amendments made by the Health Insurance (Professional Services Review Scheme) Amendment (2022 Measures No. 4) Regulations2022#

13Amendments made by the Health Insurance (Professional Services Review Scheme) Amendment (Prescribed Pattern of Services) Regulations2026#