Medical practitioner guidelines
Who can provide medical practitioner services?
You can provide services if you are a medical practitioner registered under the Health Practitioner Regulation National Law (e.g. AHPRA) to practice in the medical profession (other than as a student).
What we can pay for
We can pay the reasonable costs of medical treatment, without prior approval, when it is required as a result of a transport accident injury.
We will review our client’s treatment to ensure it’s reasonable, clinically justified, outcome focused and in line with the Clinical Framework. We'll ask you and our client for information during these reviews and may temporarily stop funding treatment if we don’t receive it.
Reviews help us understand our client’s injuries, treatment needs, their goals and how to best support them get their lives back on track. After a review we’ll let you and our client know the decision regarding further treatment.
We can pay for:
- medical services with an MBS item number
We can pay for medication that is:
- prescribed in accordance with the PBS
- registered on the Australian Register of Therapeutic Goods
See our Medication guidelines for further information.
We can pay for:
- the provision of basic equipment
We can pay for:
- Travel costs, where it is clinically justified to conduct treatment in the community.
- Travel time, for travel to and from the practitioner's practice address and the appointment location. When more than one client is visited in a single travel period, total travel costs should be apportioned equally between clients.
Family and group services
We can pay for:
The Family Counselling Allowance applies per claim, regardless of how many eligible family members access this service. The applicable amount for each claim is dependent on when a family member first accessed the service. This allowance is the maximum amount we can pay for family counselling, as set out in the Transport Accident Act 1986. This amount is indexed annually.
Note: “Family member” refers to any member of the immediate family (i.e. partner, parent, sibling or child) of the person who dies or is severely injured as a result of a transport accident. A parent of a dependent child includes:
- A person who has day-to-day care and control of the child, with whom the child is normally resident.
- A guardian of the child.
You may refer patients to a number of services. We will pay for these services without prior approval.
- allied health
- basic medical and rehabilitation equipment, such as continence equipment and dose administration aids
- family counselling, performed by a social worker or psychologist
You may also refer patients to specialist services. These services require our approval prior to payment.
- in vitro fertilisation
- Multiple and Complex Needs Model
- infusion therapy for pain management
- obstetrics including pregnancy (termination of)
- spinal injection therapies
Other services that require our approval prior to payment include:
- domestic services such as home help, gardening and child care
- weight loss treatment and services
Surgery and hospital admissions
- Surgical procedures that occur in the first three months from the date of the transport accident do not require prior approval.
- For surgical procedures after the first three months, prior approval from us is required.
- If the patient has a severe injury, surgery is pre-approved for 12 months from the date of the transport accident.
How do I request surgery approval?
Requests for surgical procedures after three months should be submitted in writing and include:
- The name and claim number of the client.
- The name of the medical practitioner performing the surgery.
- A brief description of the specific elective surgery.
- The MBS item number(s) associated with the specific elective surgery requested.
- Clinical indication for elective surgery and the relationship between the surgery and your patient’s transport accident injuries.
- Details of anticipated prostheses, including clinical justification for the use of a gap-permitted or unlisted item, if required.
We will accept the above information in a letter from a surgeon to a third party, such as the referring GP, if it is provided to us with notification from the surgeon clearly stating that this is a request for funding.
For surgical procedures performed in a public or private hospital operating theatre, the principal surgeon must provide the hospital operation report generated at the time of the surgical procedure.
This should include:
- Patient's name and date of birth.
- Date of surgery.
- Date of report.
- Name of the principal surgeon.
- Name of assistants.
- Description of all services performed: the approach, procedure, closure, any prostheses used and the side and site of the procedure. This is particularly important when more than one procedure is being performed.
- Appropriate item numbers.
- A signature/authorisation.
You only need to provide a report when we request it. In some cases we may contact you regarding your patient’s treatment and services. We may send you a customised request for a report and ask you to include information regarding the patient’s history, diagnosis, prognosis, progress, outcomes, capacity for work and medical management.
Types of reports we may request:
- short report (up to 3 questions)
- standard report (4 to 6 questions)
- comprehensive report (7 to 10 questions)
- other specific reports
For general practitioners, we will pay for these reports in line with the Medical reports (TAC requested) fees: treating medical practitioners.
For other medical practitioners, will pay for these reports in line with:
- The scheduled fee as listed by the Department of Health and Human Services (Vic)
- Our Medical services reimbursement rates
Other things to note
For accidents that occurred prior to 14 February 2018 a medical excess may apply. Visit the medical excess page to see if it applies to your patient. If the medical excess applies you will need to invoice the client directly.
Gap in treatment
If our client has not received treatment 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 you haven’t seen them in 6 months.
Certificate of capacity
As part of your patient’s treatment, you may be required to complete Certificates of Capacity to assess and certify your patient’s capacity for work.
Patients with a severe injury
If your patient has a severe injury, your discussions, referrals and approval of services may form part of the independence planning process between the patient's treating team and our TAC coordinator.
If your patient already has an individualised funding package, medical services may be included as part of that.
How much we can pay
For payment of surgical services, we have adopted the MBS explanations, definitions, rules and conditions for services provided by medical practitioners – with the following exceptions:
Multiple operations – orthopaedic operations only
- 100% for the item with the greatest TAC fee, plus 75% for each other item
- For multiple dislocations or fractures requiring an operative or manipulative procedure, the fee for each dislocation or fracture shall be 100% of the TAC fee.
- For multiple dislocations or fractures where the second or subsequent conditions do not require operative or manipulative treatment, the fee for the second and each subsequent procedure shall be 75% of the TAC fee.
- When fractures or dislocations are associated with a compound (open) wound, an additional fee of 50% of the fracture or dislocation fee shall apply. The additional 50% applies only to the fracture or dislocation fee and does not apply to the fees for any other procedures that may be performed during the surgery. The medical practitioner must state on their invoice 'Open' or 'Compound' next to the procedure item number.
- Except where otherwise specified by the TAC, the fee for a fracture-dislocation to the same site shall be the fee for the fracture or dislocation, whichever is the greater, plus 50% of the TAC fee for the lesser procedure.
Fracture and dislocations for two or more operations performed on a patient on the one occasion:
What we cannot pay for
We cannot pay for:
- treatment and services that are included in a hospital inpatient bed fee
- the provision of a hospital operation report
- GP participation in a GP return to work case conference that is not initiated by us or the vocational rehabilitation provider
- hire charges for surgical equipment associated with a patient’s surgery procedures