Surgery (Elective)

The TAC Medical Excess may apply to these services

This policy must be read in conjunction with the:

Policy

The TAC can fund the reasonable cost of elective surgery for a client that is provided by a suitably qualified medical practitioner and is required as a result of his/her transport accident injuries.

The TAC has adopted the Medicare Benefits Schedule (MBS) items, explanations, definitions, rules and conditions for surgical services provided by suitably qualified medical practitioners.

When billing for elective surgery, medical practitioners are expected to adhere to the MBS rules unless otherwise specified by the TAC in this policy, other TAC policies within the 'Medical Services' section of the TAC website, or the TAC Reimbursement Rates for Medical Services information sheet.

See also the Surgical Procedures section of the Medical Practitioners policy.

Transport Accident Act 1986 reference: s.3 'medical service' and s.60

DEFINITION

In this policy, elective surgery is clinically necessary, non-emergency surgical treatment (including surgical procedures) performed by a suitably qualified medical practitioner.

Emergency surgery is not covered in this policy.

Guidelines

What can the TAC fund in relation to elective surgery?

The TAC can fund the reasonable costs of:

  • surgical services that have an item number in the Medicare Benefits Schedule and are invoiced in accordance with the fees listed in the TAC Reimbursement Rates for Medical Services
  • surgical services which are required as a result of a transport accident, and
  • surgical services which are requested and performed by a suitably qualified medical practitioner, and
  • hospital and theatre fees in accordance with the relevant TAC Private or Public hospital fee schedule arrangement, refer to the Hospitals policy and the Department of Health Fees Manual, and
  • surgically implanted prosthetic items as listed on the current Prostheses List published by the Commonwealth Department of Health.

What information does the TAC require to consider funding elective surgery?

To facilitate a timely decision and payment of invoices, the TAC encourages prior approval be sought and the information listed below be provided in writing by the client's medical practitioner:

  1. Name and claim number of the client
  2. Name of the medical practitioner performing the elective surgery
  3. Brief description of the specific elective surgery
  4. The MBS item number/s associated with the specific elective surgery requested
  5. Clinical indication for elective surgery and the relationship between the surgery and the client's transport accident injuries
  6. Details of anticipated prostheses, including clinical justification for the use of a gap-permitted or unlisted item, if required. Refer to the Surgically Implanted Prostheses policy.

The TAC will accept the above information in a letter from a surgeon to a third party, for example, the referring GP.  This should be provided to the TAC with notification from the surgeon clearly stating that this is a request for funding.

What invoicing information does the TAC require from medical practitioners?

For details on the information required when submitting invoices for elective surgery, refer to the Medical Practitioners policy and the TAC Invoicing Guidelines for Medical Practitioners.

The invoice may be subjected to a review process and item numbers will only be funded if they are billed in accordance with the Medicare Benefits Schedule and the relevant TAC policies. Each benefit claimed must be supported by adequate detail in the hospital operation report as per the stated Medicare Benefits Schedule. See also the 'Hospital Operation Report' section of the Medical Practitioners policy.

When can the TAC fund surgically implanted prostheses?

Refer to the Surgically Implanted Prostheses policy.

When will I receive a response from the TAC?

Within 10 working days of receiving an elective surgery request, TAC will advise whether:

  • the request has been approved, or
  • the request has been denied, or
  • further information is required to make a decision.

Where further information is required, the TAC will advise whether the elective surgery request has been approved or denied within 10 working days of receiving the additional information.

Can the TAC fund elective surgery performed by a member of a client's immediate family?

Refer to the Funding Treatment by a Member of a Client's Immediate Family policy.

Can the TAC fund elective surgery which is not listed on the Medicare Benefits Schedule?

In exceptional circumstances elective surgery which is not listed on the Medicare Benefits Schedule may be considered. Such requests must meet the requirements of the Non-Established, New or Emerging Treatments and Services policy.

In relation to elective surgery what will the TAC not fund?

The TAC will not fund:

  • treatment or services that are not in accordance with the MBS explanations, definitions, rules and conditions for services provided by medical practitioners unless otherwise specified by the TAC
  • the provision of hospital operation reports, as these reports form part of the surgical service and are generated at the time of the surgical procedure
  • treatment or services for a person other than the injured client
  • treatment or services for a condition that existed before the transport accident or that is not a direct result of the transport accident
  • treatment or services where there is no objective evidence that a treatment or service is safe and effective
  • non-attendance fees where a client failed to attend unless the MBS states otherwise
  • the cost of telephone calls and telephone consultations between providers and clients, and between other providers, including hospitals
  • treatment or services subcontracted to a non-registered provider
  • treatment or services provided outside the Commonwealth of Australia
  • gap-permitted prosthetic items, or prosthetic items not listed on the Prostheses List (any exceptions require prior written approval from the TAC)
  • treatment or services provided more than 2 years prior to the request for funding except where the request for payment is made within 3 years of the transport accident. Refer to the Time Limit to Apply for the Payment of Medical and Like Expenses policy.

Other TAC policies related to this policy:


Medical Services Reimbursement Rates

The TAC has adopted the Medicare Benefits Schedule (MBS) items, explanations, definitions, rules and conditions for services provided by medical practitioners.  When invoicing for medical services, medical practitioners are expected to adhere to the MBS rules unless otherwise specified by the TAC in the Reimbursement Rates for Medical Services booklet or its medical policies.

The Reimbursement Rates for Medical Services booklet below must be read in conjunction with:

Current Rates

Previous Rates

At the time of production this publication contained up to date information as released by Medicare Australia (Medicare).  The relevant publication will be updated to reflect any further changes that are implemented by Medicare each year.  Please check our website for the latest version.

If you have any questions about these publications or the reimbursement rates, please contact the TAC on 1300 654 329. Alternatively, e-mail info@tac.vic.gov.au.


View Invoicing Guidelines for Medical Practitioners

Invoicing Guidelines for Medical Practitioners

Summary:

This fact sheet provides guidelines for Medical Practitioners to follow when submitting their accounts to prevent delays in payment. 

View Reimbursement Rates for Medical Services Information Sheet

Reimbursement Rates for Medical Services Information Sheet

Summary: This Information sheet provides an introduction to TAC's fee schedule for Medical Practitioners.