Health Insurance Act 1973

For the purposes of paragraph 20A(2)(e), this subsection applies to the assignor’s right to the payment of a medicare benefit in respect of a professional service rendered by, or on behalf of, a person (the professional) while hospital treatment or hospital‑substitute treatment is provided if:

any of the following conditions is satisfied:

the insurer concerned has an arrangement with the professional for the provision of treatment to persons insured by the insurer;

in the case of hospital treatment authorised by the operator of a hospital (see subsection (7))—the insurer has an arrangement with the operator of the hospital for the provision of treatment to persons insured by the insurer, and the operator of the hospital has an arrangement with the professional under which treatment is provided to persons insured by the insurer;

in the case of hospital‑substitute treatment authorised by an organization (see subsection (7))—the insurer has an arrangement with the organization for the provision of treatment to persons insured by the insurer, and the organization has an arrangement with the professional under which treatment is provided to persons insured by the insurer; and

the arrangement or arrangements (as the case may be) cover (wholly or partly) a liability of the insurer, the operator of the hospital or the organization to pay fees and charges in respect of the professional service; and

the right to payment of the medicare benefit has not been assigned under an agreement entered into under subsection 20A(1).

For the purposes of subsection 20A(2A), if subsection (1) of this section applies to the assignor’s right to the payment of the medicare benefit in respect of the professional service, it is taken to be assigned to whichever of the following is applicable:

if the claim for the medicare benefit is made by an approved billing agent—the approved billing agent;

otherwise—the insurer.

The insurer or approved billing agent must notify the assignor, or, if the medicare benefit relates to a professional service rendered to another eligible person, that other person, within 6 months of being paid the medicare benefit: see subsection 127(3).

For the purposes of paragraph 20A(2)(e), this subsection applies to the assignor’s right to the payment of a medicare benefit in respect of a professional service rendered by, or on behalf of, a person (the professional) while hospital treatment or hospital‑substitute treatment is provided if:

unless paragraph (b) applies—the medicare benefit is covered by a request made by the assignor for the purposes of this paragraph, in accordance with requirements specified in the regulations, to the following person (the responsible provider):

in the case of hospital treatment authorised by the operator of a hospital (see subsection (7))—the operator of the hospital;

in the case of hospital‑substitute treatment authorised by an organization (see subsection (7))—the organization;

in the case of hospital‑substitute treatment to which subparagraph (ii) does not apply—the professional; and

if a request mentioned in paragraph (a) has been modified, in accordance with requirements specified in the regulations, after the professional service is rendered, by the responsible provider or a person authorised by the responsible provider—the medicare benefit is covered by the request as modified; and

the request, or the request as modified (as the case may be), provides that the assignor’s right to the payment of the medicare benefit in respect of the professional service is to be assigned to the insurer concerned or an approved billing agent; and

any requirements specified in the regulations are met; and

the right to payment of the medicare benefit has not been assigned under an agreement entered into under subsection 20A(1), or because of the operation of subsection (1) or (5) of this section.

The operator of the hospital, the organization or the professional (as the case may be) must, if asked to, give the assignor a copy of the terms of a request made under paragraph (3)(a): see subsection 127(4).

The operator of the hospital, the organization or the professional (as the case may be) must, if asked to, give the assignor a copy of the terms of a request that is modified as mentioned in paragraph (3)(b): see subsection 127(5).

For the purposes of subsection 20A(2A), if subsection (3) of this section applies to the assignor’s right to the payment of the medicare benefit in respect of the professional service, it is taken to be assigned to the insurer or approved billing agent mentioned in paragraph (3)(c) of this section.

The insurer or approved billing agent must notify the assignor, or, if the medicare benefit relates to a professional service rendered to another eligible person, that other person, within 6 months of being paid the medicare benefit: see subsection 127(3).

For the purposes of paragraph 20A(2)(e), this subsection applies to the assignor’s right to the payment of a medicare benefit in respect of a professional service rendered by, or on behalf of, a person (the professional) while hospital treatment or hospital‑substitute treatment is provided if:

another professional service (the related professional service) is rendered while the hospital treatment or hospital‑substitute treatment is provided; and

the right to payment of the medicare benefit in respect of the related professional service is taken to be assigned to the insurer concerned or an approved billing agent because of the operation of subsection (1) or (3) of this section; and

the professional service:

is rendered for a complication that arises during the related professional service; or

is unplanned but is rendered during planned treatment of which the related professional service is part, and is, in the view of the professional, necessary and urgent; and

the right to payment of the medicare benefit has not been assigned under an agreement entered into under subsection 20A(1), or because of the operation of subsection (1) of this section.

For the purposes of subsection 20A(2A), if subsection (5) of this section applies to the assignor’s right to the payment of the medicare benefit in respect of the professional service, it is taken to be assigned to the insurer or approved billing agent mentioned in paragraph (5)(b) of this section.

The insurer or approved billing agent must notify the assignor, or, if the medicare benefit relates to a professional service rendered to another eligible person, that other person, within 6 months of being paid the medicare benefit: see subsection 127(3).

For the purposes of this section, the operator of a hospital, or an organization, authorises the provision of hospital treatment, or hospital‑substitute treatment, to a patient if:

the operator of the hospital, or the organization, is a body corporate or a body politic; and

the treatment is provided:

by a person who is authorised by the operator of the hospital, or the organization, to provide the treatment; or

under the management or control of such a person.

In this Act, a hospital is a facility for which a declaration under subsection 121‑5(6) of the Private Health Insurance Act 2007 is in force: see subsection 3(1) of this Act and subsection 121‑5(5) of the Private Health Insurance Act 2007.

Without limiting this section, regulations prescribing requirements for the purposes of this section may specify:

requirements relating to the content of requests or modifications to be made, or the manner and form in which the requests or modifications are to be made; and

requirements relating to information that must be given and the manner and form in which the information must be given; and

requirements relating to the giving of notifications at the time or after modifications are made, or before or after information is given; and

in relation to the making or modifying of a request—the circumstances in which the request may be made or modified.

Regulations made for the purposes of paragraph (c) of this subsection may specify that paragraph 127(6)(c) applies. Subsection 127(6) is a civil penalty provision.