Private hospital guidelines
These guidelines should be read in conjunction with our General provider guidelines.
Who can provide private hospital services?
Services can be provided by:
- a private hospital within the meaning of the Health Services Act 1988, or
- a private hospital within the meaning of a law of another state or territory
Different hospital arrangements
We have different arrangements with private hospitals.
These facilities have a written contract with us about the provision of hospital services for our clients:
- Epworth: Brighton, Camberwell, Cliveden, Eastern, Freemasons, Geelong, Richmond, Hawthorn, Berwick Specialist Centre, Lilydale Specialist Centre, Radiation Oncology at South West Regional Cancer Centre
- Healthscope: Victorian Rehabilitation Centre, North Eastern Rehabilitation Centre
- Healthe Care: Brunswick Private Hospital, South Eastern Private Hospital, Mulgrave Private Hospital (formerly The Valley Private Hospital) and Epping Private Hospital
These facilities have agreed fees payable by us for services provided to our clients:
- Cabrini: Malvern and Brighton
- Healthscope: Dorset Rehabilitation Centre, Holmesglen Private Hospital, Knox Private Hospital and The Melbourne Clinic
- Ramsay Health Care: The Avenue Private Hospital, Donvale Rehabilitation Hospital, Peninsula Private Hospital, Linacre Private Hospital and Warringal Private Hospital
- Jessie McPherson Private Hospital
- St John of God Hospital (Ballarat)
By agreeing to provide services to our clients, you agree to adhere to the conditions set out in these guidelines.
These facilities provide hospital services in line with the TAC guidelines and the Non-Arrangement fee schedule.
What we can pay for
We 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).
We will periodically review your patient’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.
Gap in treatment
If our client has not received a treatment or service in 6 months they will need to seek approval from us before we will pay for further treatment. Ask our client for a copy of their approval if it's been 6 months since they last had a treatment or service paid for by the TAC.
Inpatient accommodation classifications
Inpatient accommodation classifications are allocated by private hospitals for each admission.
The applicable TAC hospital admission classifications are:
- Surgical: Advanced Surgical (AS), General Surgical (GS), Day Surgery
- Medical: Special Medical (SM), General Medical (GM)
- Specialised units: Intensive Care (ICU), Coronary Care (CCU), High Dependency (HDU)
- Home based care: Hospital in the Home (HITH)
- Rehabilitation in the Home (RITH)
Medical admissions are classified as either General Medical or Special Medical. This is determined using the ICD-10-AM code, which denotes the primary condition requiring admission, and the medical admissions ready reckoner we provide to each hospital.
If our client is reclassified from General Medical to Special Medical in the same inpatient period, a new step-down period will commence from the date of reclassification.
If our client’s accommodation classification changes from Special Medical to General Medical, the accommodation step-down period will continue.
Surgical admissions are classified as either General Surgical or Advanced Surgical. This is determined using the MBS item number appropriate to the surgical procedure performed and the Banding List.
We 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.
We can pay for our client’s inpatient admission following a dental procedure under the General Surgical classification if the procedure does not have a corresponding surgical MBS item number.
When a patient 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 continue.
Same day admissions
Same day admission applies to patients who are admitted to undergo a procedure that requires observation in hospital, but can be discharged on the same day.
This includes any medical/surgical item we recognise, except consultations or 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 our theatre band schedule based on the Banding List.
Specialised unit admissions
The ICU and CCU accommodation classifications are Intensive Care Unit (ICU), Coronary Care Unit (CCU), and High Dependency Unit (HDU) Admissions. These 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 as per the applicable Private hospital (non-arrangement) services fees.
If additional ICU/CCU or HDU bed days are required, information supporting the need for ongoing accommodation in critical care should be provided to us as soon as possible after admission. This information may be reviewed by our Clinical Panel.
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.
We can pay for inpatient rehabilitation where the program is aimed at restoring or improving patient function. The program must be multidisciplinary and focus on safe discharge to the patient's home and community.
For TAC contracted hospitals, the allocated Australian National Subacute and Non-Acute Patient (AN-SNAP) classification determines the rehabilitation classification.
For arrangement and non-arrangement hospitals, ICD-10-AM codes denote the primary reason for rehabilitation in accordance with our ready reckoner that we provide to each hospital.
Provided the rehabilitation program continues, surgical procedures performed during a rehabilitation inpatient admission do not require the client to be reclassified as a Surgical Admission.
We 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.
We can also pay for transport for our client to attend an outpatient service.
A psychiatric admission refers to a patient admitted into hospital for the purpose of undertaking a specific psychiatric treatment program.
If emergency psychiatric treatment is required, the hospital should notify us of the hospital admission as soon as possible, and supply supporting documentation if required.
Emergency psychiatric admission is defined in these guidelines as the admission of a patient 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 caregivers due to a transport accident injury, and
- admitted to a private hospital as an emergency patient for the purpose of undertaking a specific psychiatric treatment program
Home based care admissions
Hospital in the Home (HITH) admissions provide acute hospital inpatient type care that is delivered to clients in their private residence.
HITH admissions must only occur when a client would otherwise be treated in an acute inpatient capacity.
We consider it reasonable to pay a HITH daily rate only on the occasions the treating hospital conducted a patient visit.
Emergency Department (ED)
We can pay an Emergency Department (ED) facility fee when the hospital is approved to provide emergency services by the Department of Health.
The ED facility fee is only payable when our client is not subsequently admitted as an inpatient.
Services included in the inpatient bed fee – all private hospitals:
- accommodation costs in a shared ward (private room surcharges are not payable)
- nursing services
- dietary requirements, including meals, nasogastric feeds and dietary supplements
- copy of admission information, operation report and discharge summary
- consumable or disposable products
Services included in the inpatient bed fee – contracted or arrangement hospitals:
- allied health services
- aids and equipment used while in hospital
- pharmacy items required as a result of the transport accident injury
- attendant and personal care support
- treatment or services provided by third party providers, such as non-hospital employed staff
- orthoses or external prosthesis items priced below $250 per item
- interpreter services
Services that we can pay for in addition to the inpatient bed fee:
- medical treatment provided by a registered medical practitioner (see our Medical practitioner guidelines)
- surgically implanted prostheses
- theatre fees, including all disposables and consumables required for surgery
- patient transport to another treatment facility or for leave from hospital
- discharge medications (up to one month’s supply) related to the transport accident injury
- equipment provided to the patient at the time of discharge which is related to the transport accident injury
- allied health services at non-arrangement hospitals
- pharmacy items at non-arrangement hospitals
Bed hold and bed leave
We can pay for a hospital bed to be held when a patient:
- is treated at another facility (bed hold)
- takes leave from the hospital to assist with the transition from hospital to community (bed leave)
- We can pay bed hold or bed leave fees for a patient to be absent from hospital for a maximum of seven consecutive days during an inpatient admission.
- We can only pay for a maximum of 28 days of bed leave for a patient per financial year.
- Bed hold or bed leave days count towards step-down periods.
Operating theatre procedures
We can pay theatre fees if a patient 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 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.
We 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.
We pay theatre fees for multiple procedures undertaken during the same surgery, as per the below sliding scale:
Type of procedure
Highest banded MBS procedure
Next highest procedure
Third and subsequent procedures
We may request a discharge summary following an admission to an acute, rehabilitation or psychiatric facility.
If requested, rehabilitation hospitals are required to include the total motor and cognitive FIM (Functional Independence Measure) scores on the discharge summary.
What we cannot pay for
We cannot pay for:
- additional fees associated with single room accommodation
- incidental items that occur as part of a patient’s inpatient admission, such as telephone calls, entertainment systems, television hire, general toiletries, newspapers, visitor meals
- private room surcharges