The TAC can pay the reasonable costs of private hospital services when required as a result of a transport accident injury under section 60 of the Transport Accident Act 1986 (the Act).
The TAC will periodically review a client's entitlement to private hospital services to ensure that the treatment and services remain reasonable for the transport accident injury and are payable under the Act.
Private hospital services can be provided in either an in-patient setting (requires admission to hospital for overnight stay) or an outpatient setting (does not require overnight stay in hospital and may be provided in a non-hospital location) and may be for acute (to stabilise and treat) or rehabilitation (to restore or improve function) purposes.
Private hospitals assign International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) codes to all patients admitted to acute and rehabilitation hospitals. These codes note all the injuries, diagnoses or symptoms applicable to that hospital admission.
In-patient admissions are given in-patient accommodation classifications by private hospitals to assist with billing, according to whether the admission is for acute or rehabilitation purposes.
Depending on the arrangement between the hospital and the TAC, billing for in-patient admissions can include:
- fees for items/services that are grouped together to form the in-patient 'bed fee' and/or
- fees for items/services that are paid in addition to the bed fee.
In-patient billing step-down periods apply based on the reason for admission and the duration of stay and differ between admission classifications.
For TAC billing purposes, there are currently three types of private hospitals:
- contracted hospitals
- arrangement hospitals
- non-arrangement hospitals.
A contracted hospital is a hospital that has a written contract with the TAC about the provision of hospital services for TAC clients. This policy is supported by the conditions set out in the contract.
An arrangement hospital is a hospital which has individually agreed fees payable by the TAC for services that may be provided to a client. By agreeing to provide services to clients, the hospital agrees to adhere to the conditions set out in this policy.
A non-arrangement hospital is a hospital which has no previously agreed arrangement for fees and services for clients with the TAC. In providing services to clients, the TAC will pay the reasonable costs of hospital services for clients in accordance with this policy and the TAC's Private Hospital Non-Arrangement fee schedule.
In this policy:
- A private hospital is a hospital that is privately funded through payments by patients or by insurers, e.g. it is not owned by the state or federal Governments.
- In-patient services refer to treatment and other hospital services provided to clients who require admission to a hospital for overnight care.
- Outpatient services are hospital services provided to clients who do not require or no longer require admission to a hospital.
- Acute hospital services are hospital services provided to clients following an acute injury or illness. Acute hospital services are expected to be used for short-term medical and/or surgical treatment and care.
- Rehabilitation hospital services are hospital services provided to in-patients or outpatients to improve a client's function.
- An in-patient bed day is a period spent in hospital with the expectation of at least one overnight stay.
- Day count refers to the number of in-patient bed days in a hospital admission, calculated on the number of nights (time past midnight) spent in hospital from the first day of the in-patient episode. When a client is re-admitted to hospital within seven days of discharge (regardless of the change in classification or hospital) the day count will continue, taking into account previous days spent in hospital. When a client is re-admitted after eight or more days from discharge, a new day count will commence from the first day of the re-admission.
- A bed fee is the fee charged per in-patient bed day for a client's in-patient admission, according to the reason for admission and the relevant fee schedule. The bed fee may 'step down' during a client's in-patient admission.
- A step-down period is a defined number of days beyond which the bed fee reduces to a lower rate. The step-down period varies according to reason for admission.
What can the TAC pay for in relation to private hospital services?
The TAC can pay the reasonable costs of private hospital services in an in-patient or outpatient setting, for acute or rehabilitation purposes, when the services are:
- required as a result of the transport accident injury
- reasonable, necessary or appropriate in the circumstances
- clinically justified, safe and effective
- in accordance with the TAC's policies
- payable by the TAC under the Transport Accident Act 1986
- payable in accordance with contracted hospital or arrangement hospital agreements (if applicable).
The TAC can pay the reasonable costs of private hospital in-patient services as part of the in-patient bed fee and/or in addition to the bed fee.
The following private hospital services are included in the TAC in-patient bed fee:
- All accommodation costs in a shared ward
- Nursing services
- Dietary requirements including meals, naso-gastric feeds and dietary supplements
- Copy of admission information, operation report, discharge summary
- Consumable or disposable products
- The cost of all allied health services (contracted or arrangement hospitals only)
- Aids and equipment used during the hosptial stay (contracted or arrangement hospitals only)
- Pharmacy items related to the hospital episode and required as a result of the transport accident injury (contracted or arrangement hospitals only)
- Attendant and personal care support (contracted or arrangement hospitals only)
- Treatment or services provided by third party providers i.e. non-hospital employed staff (contracted or arrangement hospitals only)
- Orthoses or external prosthesis items priced below $250 per item (contracted or arrangement hospitals only)
- Interpreter services (contracted or arrangement hospitals only).
The following private hospital services can be paid for in addition to the TAC in-patient bed fee:
- Medical treatment provided by a registered medical practitioner. Refer to the Medical Practitioners policy
- Surgically implanted prostheses costs in accordance with the Surgically Implanted Prostheses policy
- Theatre fees, including all disposables and consumables required for operating room procedures
- In-patient transport for a client to receive treatment at another facility or for weekend leave from hospital. Refer to the Travel and Accommodation Expenses policy
- Discharge medications (up to one month's supply) related to the transport accident injury
- Discharge equipment related to the transport accident injury provided to a client at the time of discharge
- Allied health services (non-arrangement hospitals only)
- Pharmacy items (non-arrangement hospitals only).
Bed Hold and Bed Leave
The TAC can pay for a hospital bed to be held overnight for a client while the client is treated at another facility. A specific bed hold fee applies in this case.
The TAC can pay for a hospital bed to be held overnight or over a weekend while the client takes leave from the hospital. Leave from the hospital is used to assist clients with the transition from hospital to community. A specific bed leave fee applies in this case.
The TAC can pay bed hold or bed leave fees for a client to be absent from hospital for a maximum of seven consecutive days during an in-patient admission. The TAC can only pay for a maximum of 28 days of bed leave for a client per financial year.
Bed hold or bed leave days count towards step-down periods.
Operating Theatre Procedures
The TAC can pay theatre fees if a client undergoes a procedure which has been allocated a band number in the National Procedure Banding List (the Banding List), published by the Australian Private Hospitals Association (APHA).
The TAC considers that the theatre fee covers the costs of all consumables, disposables and drugs required during a procedure, for the actual procedure and/or anaesthetic, unless otherwise indicated in the Banding List.
The TAC can pay Band 1 theatre fees for approved dental procedures that do not have an allocated band number in the Banding List.
If multiple procedures are undertaken during the same occasion of theatre, a sliding scale is used to calculate the theatre payment required. For separate visits to theatre on the same day, the sliding scale applies independently to each occasion of theatre.
The TAC can pay theatre fees for multiple procedures undertaken during the same occasion of theatre as per the below sliding scale:
- Type of Procedure % Paid
- Highest Banded MBS procedure 100%
- Next highest procedure 50%
- Third and subsequent procedures 33%
The TAC requires the principle surgeon to provide the hospital operation report as detailed in the Medical Practitioners policy.
To facilitate prompt payment of invoices, the TAC requires a discharge summary to be provided within seven days of discharge following an admission to an acute, rehabilitation or psychiatric facility.
Rehabilitation hospitals are required to include the total motor and cognitive FIM (Functional Independence Measure) scores on the discharge summary.
In-patient accommodation classifications
In-patient accommodation classifications are allocated by private hospitals for each admission to enable accurate billing for the client's hospital admission.
The applicable TAC hospital admission classifications are:
- Advanced Surgical (AS)
- General Surgical (GS)
- Day Surgery (DS)
- Special Medical (SM)
- General Medical (GM)
- Intensive Care Unit (ICU)
- Coronary Care Unit (CCU)
- High Dependency Unit (HDU)
- Hospital in the Home (HIH)
- Psychiatric (PSY)
- Rehabilitation (REH)
- Acute hospital services - in-patient
A medical admission applies to a client who is admitted for the purposes of receiving acute medical care and services.
Medical admissions are classified as either General Medical or Special Medical, determined using the ICD-10-AM code, which denotes the primary condition requiring admission, and the medical admissions ready reckoner provided by the TAC to each hospital.
If a client is reclassified from general medical to special medical in the same in-patient period, a new step-down period will commence from the date of reclassification. Because these occurrences are rare, a letter of explanation is required from the treating medical practitioner.
If a client's accommodation classification changes from special medical to general medical, the accommodation step-down period will continue.
A surgical admission applies to a client who is admitted for the purposes of undergoing a surgical procedure and receiving post-surgical care. Surgical admissions are classified as either General Surgical or Advanced Surgical determined using the MBS item number appropriate to the surgical procedure performed and the Banding List.
The TAC can only pay for surgical bed fees up to 24 hours prior to the date on which the surgical procedure is performed. Periods of hospitalisation prior to this will be paid based on the appropriate medical classification. A new step-down period will commence from the date of reclassification.
The TAC can pay for a client's in-patient admission following a dental procedure under the General Surgical classification if the procedure does not have a corresponding surgical MBS item number.
When a client undergoes more than one surgical procedure on the same day, the accommodation classification for the total period of hospitalisation will be determined by the surgical procedure with the highest MBS value.
Where there are multiple surgeries or procedures on different days during the same period of hospitalisation:
- If the MBS item number for the subsequent surgical procedure falls within a higher accommodation classification than the initial procedure, then a new accommodation step-down period will commence from the date of the subsequent procedure.
- If the MBS item number for the subsequent surgical procedure falls within a lower accommodation classification than the initial procedure, then the original patient classification and step-down period continues.
If a client's accommodation classification changes whilst they are an in-patient, the change in details must be listed on the invoice, including the date in which it occurred.
Same Day Admissions
A same day admission applies to clients who are admitted to undergo a procedure that requires observation in hospital, but the client can be discharged on the same day. A procedure is any medical/surgical item recognised by the TAC, except consultations/attendances (as listed in Part 1 of the MBS).
Hospital accounts should quote the MBS item number of the procedure performed. A theatre fee will only be payable when the item number has been allocated a theatre band in the TAC's theatre band schedule based on the Banding List.
Intensive Care Unit (ICU), Coronary Care Unit (CCU), High Dependency Unit (HDU) Admissions
The ICU and CCU accommodation classifications only apply to hospitals that have an ICU or CCU that has been approved by the Department of Health, Victoria.
The ICU/CCU rate is payable up to a maximum of four days per hospital admission at a TAC non-arrangement hospital as per the TAC fee schedule.
Periods in an ICU, CCU, or HDU are not taken into account for the purpose of calculating bed day counts for the step-down period.
If additional ICU/CCU or HDU bed days are required in excess of the number stated in the fee schedule, clinical justification and information supporting the need for ongoing accommodation in critical care should be provided to the TAC as soon as possible after admission. This information may be reviewed by the TAC Clinical Panel.
A psychiatric in-patient means a client is admitted into hospital for the purpose of undertaking a specific psychiatric treatment program.
The admitting private hospital or treating medical practitioner must receive prior approval from the TAC, except where emergency psychiatric treatment is required.
As an emergency psychiatric admission is an exceptional circumstance, the admitting hospital is not required to obtain prior approval from the TAC (see definition below). However, the hospital should notify the TAC of the hospital admission as soon as possible. Information to support the emergency psychiatric admission is required from the admitting hospital within three days of the admission and the TAC will expedite the approval where possible.
Emergency psychiatric admission is defined in this policy as the admission of a client who is:
- at risk of self harm or harm to others, and/or
- experiencing extreme subjective distress, and/or
- causing extreme distress to his/her family or care givers due to a transport accident injury, and
- is admitted into a private hospital as an emergency patient for the purpose of undertaking a specific psychiatric treatment program.
A copy of the Psychiatric Assessment Certificate must be sent to the TAC with the final in-patient account.
Hospital in the Home Admissions (HIH)
A HIH admission provides hospital in-patient type care that is delivered to clients in their private residence after a period of acute care in a hospital or instead of a hospital admission. HIH admissions must only occur when a client would otherwise be treated in a hospital.
The TAC considers it reasonable to pay a HIH daily rate only on the occasions the treating hospital conducted a patient visit.
For more information on fees, please see the relevant arrangement or non-arrangement Private Hospital fee schedule.
Prior approval is not a prerequisite for HIH services to commence, however the TAC requires notification five (5) working days prior to the cessation of HIH services if ongoing services are required.
Rehabilitation hospital services - in-patient
A client is admitted to in-patient rehabilitation for the purpose of undertaking a specific rehabilitation program aimed at restoring or improving their function.
The treating medical practitioner must receive prior approval from the TAC for the rehabilitation admission. It is expected that the admitting rehabilitation hospital will confirm that liability for the service has been accepted before the rehabilitation admission occurs.
The ICD-10-AM code which denotes the primary reason for rehabilitation, determines the rehabilitation classification in accordance with the TAC ready reckoner provided by the TAC to each hospital.
Provided the rehabilitation is continuing, surgical procedures performed during a rehabilitation in-patient admission do not require the client to be reclassified as a Surgical Admission. If the surgical procedure interrupts the rehabilitation program, the appropriate surgical classification should be assigned.
The TAC cannot pay for Rehabilitation in the Home (RITH) admissions within the private sector.
Note: For TAC contracted hospitals, the allocated Australian National Subacute and Non-Acute Patient (AN-SNAP) classification determines the rehabilitation classification.
What information does the TAC require to consider paying for in-patient private hospital services?
The TAC strongly encourages prior approval be sought for all private hospital admissions (acute, rehabilitation and psychiatric) to avoid any delays in payment.
The TAC requires the following information in writing from the treating medical practitioner for each hospital admission:
- the clinical diagnosis, injury or symptoms (in the absence of a diagnosis) resulting in the in-patient admission
- how the diagnosis, injury or symptoms relate to the transport accident injury
- the goals of the in-patient admission
- the proposed in-patient treatment plan and the estimated duration of in-patient admission
- the costs associated with the admission
- for psychiatric admissions only, details of any previous psychiatric treatment including in-patient psychiatric admissions, and how any non transport accident injuries influence the psychiatric presentation and need for in-patient admission.
Acute Care Certificates
The TAC requires the submission of an Acute Care Certificate with an in-patient account when a client has been hospitalised for more than 35 continuous days for surgical or medical treatment. The certificate must be signed by a medical practitioner and can be issued for a maximum period of 31 days.
A client will be reclassified and paid as a Nursing Home Type Patient where an Acute Care Certificate is not submitted for a surgical or medical patient after the first 35 days hospitalisation (or each period up to 31 days thereafter).
The TAC does not require an Acute Care Certificate for rehabilitation, long-term accommodation or respite care clients.
The TAC can pay the reasonable costs of private hospital outpatient services required for a client as a result of his/her transport accident injury.
Acute hospital services - Outpatient
The TAC can pay an Emergency Department (ED) facility fee when the services have been provided by a hospital approved to provide emergency services by the Department of Health.
The ED facility fee is payable to cover the materials and administrative costs of services provided in an emergency department.
Medical treatment provided by registered medical practitioners can be charged on a fee-for-service basis in accordance with the TAC Reimbursement Rates for Medical Services.
When the client requires an in-patient admission, an ED facility fee is not payable. If the client was seen at another hospital prior to being transferred to the admitting hospital, the initial referring hospital may be paid an ED facility fee. An ED facility fee is routinely paid only once per claim. The TAC may request additional information to support the payment of subsequent ED facility fees.
Rehabilitation services - Outpatient
The TAC can pay the reasonable costs of outpatient rehabilitation required for a client as a result of his/her transport accident injuries.
The TAC can pay outpatient rehabilitation services on a fee-for-service basis, as specified in the relevant fee schedule. The cost of consumable or disposable items is included in the outpatient fee.
The hospital should submit their request for client outpatient services to the TAC. Requests should be submitted at least 5 working days prior to the proposed outpatient rehabilitation services start date.
What information does the TAC require to consider paying for outpatient rehabilitation?
The hospital must receive written approval for the liability and cost of the outpatient services from the TAC prior to the provision of outpatient rehabilitation services.
To request outpatient services for a TAC client an Outpatient Rehabilitation Plan form (ORF1) must be submitted to the TAC. The request should include the following information:
- details of the allied health disciplines and number of services recommended
- outline of the client's current functional status
- discipline-specific goals that should be specific, measurable, achievable, relevant, and timed – SMART goals
- outcome measures to be used
- duration of the services
- the costs associated with the rehabilitation treatment.
Who can provide private hospital services?
Private hospital services can be provided by a private hospital:
- within the meaning of the Health Services Act 1988, or
* within the meaning of a law of another State or Territory.
When will the TAC respond to a request for hospital services?
The TAC will respond to written treatment and service requests as set out in the TAC Service Charter.
To assist the TAC to make a decision regarding a request for private hospital services, the request may be reviewed by the TAC Clinical Panel. The Clinical Panel may contact the requesting medical practitioner to seek further information and/or discuss the proposed treatment prior to making a recommendation to the TAC regarding the request. The TAC will respond to the request when they have received the Clinical Panel's recommendation.
What fees are payable for private hospital services?
For fees for private hospital services provided by TAC Non-Arrangement hospitals, refer to the Private Hospital Non-Arrangement fee schedule.
For fees for private hospital services provided by TAC Contracted or Arrangement hospitals, refer to the individual hospital agreement.
In relation to private hospital services, what won't the TAC pay for?
The TAC will not pay for:
- hospital services for a person other than the client
- non-attendance fees where a client failed to attend
- additional fees associated with single room accommodation
- hospital services provided outside the Commonwealth of Australia
- treatment and services for an injury, condition or circumstance that existed before the transport accident or that is not a direct result of a transport accident
- treatment or services provided by telephone or other non face-to-face mediums
- telephone calls and telephone consultations between providers and clients, and between other providers, including hospitals
- incidental items that occur as part of a client's in-patient admission, e.g. telephone calls, television hire, general toiletries, newspapers, visitor's meals, etc.
- treatments, services, prostheses or equipment where there is no National Health and Medical Research Council level 1 or 2 evidence that the treatment, service, prosthesis or equipment is safe and effective. Refer to the Non-Established, New or Emerging Treatments and Services policy
- treatment or services provided more than two years prior to the request for funding except where the request for payment is made within three years of the transport accident. Refer to the Time Limit to Apply for the Payment of Medical and Like Expenses policy.
Private hospital (non-arrangement) services
Effective 1 July 2017
|Service Description||TAC Item Number||2017/2018 Maximum |
|Advanced Surgical Patients||1 - 14 Days||$732.64||$714.91|
|15 + Days||$563.78||$550.14|
|General Surgical Patients||1 - 14 Days||$656.07||$640.19|
|15 + Days||$563.78||$550.14|
|Special Medical Patients||1 - 14 Days||$656.07||$640.19|
|15 + Days||$555.70||$542.25|
|General Medical Patients||1 - 14 Days||$512.79||$500.38|
|15 + Days||$473.00||$461.55|
|Psychiatric Patients||1 - 30 Days||$656.07||$640.19|
|31 - 65 Days||$555.70||$542.25|
|66 + Days||$473.00||$461.55|
|Rehabilitation Patients||1 - 25 Days||$640.19||$624.70|
|26 + Days||$488.88||$477.05|
|Intensive Care Unit^||1 - 4 Days||$1,789.50||$1,746.19|
|5 + Days||Original Patient Classification or High Dependency Unit|
|Intensive Care Unit (Metropolitan)^||1 - 4 Days||$2,679.39||$2,614.55|
|5 + Days||Original Patient Classification or High Dependency Unit|
|Coronary Care Unit^||1 - 4 Days||$1,596.80||$1,558.16|
|5 + Days||Original Patient Classification or High Dependency Unit|
|High Dependency Unit |
Hospitals must seek recognition of HDU's from the TAC prior to any payments being considered.
|1 - 3 Days||$1,109.79||$1,082.93|
|4 + Days||Original Patient Classification|
|Nursing Home Type Patient |
Applies when an Acute Care Certificate is not submitted to TAC for a surgical or medical patient after 35 days hospitalisation or each period up to 31 days thereafter.
|Same Day Patient Bed Fee |
Only applicable if a procedure or operation is performed.
|Bed Leave / Hospital Leave Fee||75% of the applicable bed fee|
|Hospital in the Home||HIT||$367.42||$358.53|
|Facility Fee - Emergency Department Patients |
A facility fee is only payable to hospitals with an approved Emergency Department.
|(Individual approval is required for electroconvulsive therapies)|
|Therapy Services||Refer Outpatient Services|
|^Reimbursements will be made only to hospitals with approved facilities|
These fee and item numbers also apply to therapy services provided to Inpatients.
|Fees are for 30 minute sessions unless otherwise stated. For times greater than 30 minutes, fees are charged in 15 minute units.|
|Hydrotherapy (by a Physiotherapist)|
|Driving Assessment by Occupational Therapist||99921||$54.94||$53.61|
Driving Instruction By Driving School (30 minutes) |
(charge in 30 minute units)
|Worksite / Home Assessment & Report (charge in 30 min units)||99967||$49.81||$48.60|
Worksite / Home Assessment & Report |
(charge in 30 min units)
|Rehabilitation Assessments & Reports|
|Initial Assessment and Preparation of Rehabilitation Plan||99904||$555.34||$543.85|
|Medical & Like Report / Reviews (Only payable when requested by TAC)||99905*||$211.97||$206.84|
|Special Education / Accredited Teacher|
^Reimbursements will be made only to hospitals with approved facilities
*The TAC maximum fee includes a 10% allowance for GST for items which TAC believes are taxable supplies. If you are a provider not registered for GST:
- You are not legally permitted to charge GST
- You should indicate on all invoices submitted your status as 'not registered for GST purposes'
- The TAC will only reimburse you an amount which excludes the GST component for items billed where the maximum fee includes a 10% allowance for GST
If you are not registered for GST please state on all invoices the TAC item number listed for providers not registered.
View Hospital direct equipment order form
Hospital direct equipment order form
Hospitals must use this form to directly order from the TAC's contracted equipment suppliers up to $500 per item of equipment, required in order to facilitate the effective discharge of the TAC client. Only the items listed on the 'Hospital Direct Order Equipment list ' can be ordered using this form. TAC clients must have an accepted claim before orders can be made by hospitals.
The equipment listed in the 'Hospital Direct Order Equipment list are commonly required to ensure a patient's safe discharge. Requests for other equipment not on the list or over $500 need to be made in writing to the TAC. Please follow the instructions provided in the Hospital Direct Order Form notes to ensure that orders can be processed and delivered without delay.
- Hospital direct equipment order form - EQF2 - MS Word 523.0 KB
- Hospital direct equipment order form for hospital scanning - EQF2 - MS Word 524.5 KB
- Hospital direct equipment order form notes - EQF2n - MS Word 200.0 KB
- Equipment list (Hospital Direct Orders) - PDF 811.8 KB
- Equipment list (Hospital Direct Orders) - MS Excel 0.62MB
View Outpatient Rehabilitation plan form
Outpatient Rehabilitation plan form
This form is to be completed by a client's treating team within the rehabilitation facility they're staying to prepare for their outpatient therapy program. It sets goals for the client and outlines the action plan that will help them achieve these aims. The separate 'notes' document in this section provides additional instructions and clarification to help complete the form.
View Urgent psychiatric admission: Request for funding form
Urgent psychiatric admission: Request for funding form
This form is to be completed by a registered medical practitioner to request urgent psychiatric admission for TAC clients. It requires a clinical diagnoses of the client's condition and an explanation of why the admission is needed urgently.