Referral Requirements

To claim an MBS benefit for assessment services, you must have a valid referral from an eligible medical practitioner—a consultant psychiatrist or paediatrician. The referral is only valid if the referring practitioner uses specific MBS items for the suspected diagnosis of a complex neurodevelopmental disorder (such as autism spectrum disorder).

Eligible referral items include:

• Consultant psychiatrist: Items 296–308, 310, 312, 314, 316, 318, 319–349 (General Medical Services Table), or Telehealth items 91827, 91828, 91829, 91830, 91831, 91837, 91838, 91839, 92437, 92455, 92456, 92457.
• Consultant paediatrician: Items 110–131 (General Medical Services Table), or Telehealth items 91824, 91825, 91826, 91836.

A Medicare claim for the referring service must be submitted before you can claim for the subsequent allied health assessment.

Number of Services

• Up to 8 assessment services can be claimed per patient per lifetime, using any combination of items 82000, 82005, 82010, 82030, 93032, 93033, 93040, or 93041.
• A course of assessment may include up to 4 services.
• Up to 4 services can be provided on the same day.
• If more than 4 services are required from the same allied health provider, review and agreement from the referring medical practitioner is needed before further Medicare-eligible services can be claimed.

Provision of Assessment Services & Review Requirements

• Eligible allied health practitioners can provide up to 4 assessment services without additional review.
• If further assessment services are needed, the referring medical practitioner must review and agree before more services can be provided.
• The type of review may be specified in the original referral. If not, acceptable reviews include case conferences, phone calls, written correspondence, secure online messaging, or an in-person meeting.
• The review and agreement must be documented in the patient’s notes by the allied health practitioner.

Medicare Rebate and Fees

• Our assessment fee is $250 per hour (or per session of at least 50 minutes).
• With a valid referral and eligibility, you can claim a Medicare rebate of $98.95 per eligible session.
• The rebate is fixed by Medicare and does not vary according to provider fees.
• Your out-of-pocket cost per session will be the difference between our fee and the rebate.

For more details on eligibility and claiming, please speak with your referring doctor or visit the Medicare Benefits Schedule (MBS) website.