Referral Requirements for Better Access Treatment Services

Referral Requirements for Better Access Treatment Services

Associated items: 2721, 2723, 2725, 2727, 91818, 91819, 91842, 91843, 283, 285, 286, 287, 91820, 91821, 91844, 91845, 80100, 80105, 80110, 80115, 91169, 91170, 91183, 91184, 80125, 80130, 80135, 80140, 91172, 91173, 91185, 91186, 80150, 80155, 80160, 80165, 91175, 91176, 91187, 91188, 80120, 80122, 80127, 80121, 80123, 80128, 80145, 80147, 80152, 80146, 80148, 80153, 80170, 80172, 80174, 80171, 80173, 80175, 80000, 80010, 80005, 80015, 91166, 91167, 91181, 91182, 80020, 80021, 80022, 80023, 80024, 80025, 80002, 80006, 80012, 80016, 91171, 91199, 91168, 91198

Services requiring referral

Medicare Benefits Schedule (MBS) mental health treatment services under the Better Access initiative (refer to explanatory note AN.0.78 – Better Access Initiative) require an eligible referral for a Medicare benefit to be claimed. Medicare benefits are available for up to 10 individual and 10 group therapy mental health treatment services in a calendar year. These services may consist of:

• psychological therapy services (refer to explanatory note MN.6.2 - Provision of Psychological Therapy) and/or
• focussed psychological strategies (refer to explanatory note MN.7.4 - Provision of Focussed Psychological Strategies). 

Up to 2 of a patient’s individual services may be used for family and carer participation items per calendar year. For additional information, refer to explanatory note MN.7.5 – Family and Carer Participation.  

Eligible referral services

Referrals for treatment services under the Better Access initiative should be utilised for patients who require at least a moderate level of support.

For the purposes of Better Access treatment services, a Medicare benefit will be not payable unless patients meet the eligibility and referral requirements outlined in explanatory note AN.0.78 | Better Access Initiative.

Referrals from psychiatrists and paediatricians must be made from eligible Medicare services. For specialist psychiatrists and paediatricians these services include any of the specialist attendance items 104 through 109 and items 91822, 91823 and 91833. For consultant physician psychiatrists the relevant eligible Medicare services cover any of the consultant psychiatrist items 293 to 308, 310, 312, 314, 316, 318 or 319 through 349; while for consultant physician paediatricians the eligible services are consultant physician attendance items 110 through 133.

Course of treatment and specifying the number of services in a referral

Under the Better Access initiative, a patient may be referred for up to 10 individual and 10 group therapy mental health treatment services within a calendar year. Eligible patients must be referred to mental health treatment services by either a general practitioner (GP) or a prescribed medical practitioner (PMP) at the general practice in which the patient is enrolled in MyMedicare, or regardless of whether the patient is enrolled in MyMedicare, by the patient’s usual medical practitioner who is managing the patient under a Mental Health Treatment Plan. This also includes a GP or PMP who is located at a medical practice that has provided the majority of their care over the previous 12 months or will be providing the majority of their care over the next 12 months. In addition, eligible patients can be referred under a Psychiatrist Assessment and Management Plan, or on direct referral from an psychiatrist or paediatrician.  

The referring practitioner can decide how many services the patient will receive in a course of treatment, within the maximum service limit for the course of treatment. The maximum service limit for each course of treatment is set out below: 

• Initial course of treatment - a maximum of 6 individual services.
• Subsequent course of treatment - remaining individual services up to the patient's cap of 10 services per calendar year (for example, if the patient received 6 services in their initial course of treatment, they could only receive 4 services in a subsequent course of treatment provided within the same calendar year).
• Up to a maximum of 10 group therapy mental health treatment services per calendar year.

On completion of the initial course of treatment, the eligible allied health professional providing the service must provide a written report to the referring practitioner, which includes information on:

• assessments carried out on the patient;
• treatment provided; and
• recommendations on future management of the patient's disorder (e.g. if they require a subsequent course of treatment as the initial course of individual services is only up to 6 services, with the subsequent being no more than the maximum of 10 services per calendar year), noting further treatment under the Better Access initiative should be utilised for patients who require at least a moderate level of support. 

This report will aid the referring practitioner in determining whether another course of treatment is appropriate for the management of the patient’s mental disorder.

If, in their referral, the referring practitioner:

• Does not specify the number of services
• Specifies a number of services above the maximum allowed for the course of treatment
• Specifies a number of services above the maximum allowed for the calendar year (including any services the patient has already received that year),

The eligible allied health professional must contact the referring practitioner to determine the required number of services required. If the referring practitioner cannot be contacted to confirm the required number of services, the eligible allied health professional may use their clinical judgment to provide services under the referral, noting the patient cannot receive more than:

• the maximum number of services allowed for that particular course of treatment; and
• the maximum number of services allowed in a calendar year.

Where the patient’s maximum allocation per course of treatment is unknown, the allied health professional should contact Services Australia on the Medicare Provider Enquiry Line (132 150) to confirm the patient’s remaining allocation of services. 

Referral requirements

Referrals for treatment services under the Better Access initiative should be utilised for patients who require at least a moderate level of support.

Referring practitioners are not required to use a specific Medicare form to refer patients for these services, however, AN.15.6 – Referral requirements for allied health and Aboriginal and Torres Strait Islander Health and Wellbeing Services sets out the requirements when referring patients to MBS supported allied health services.

In addition to the referral requirements outlined in AN.15.6, it must be noted that a Mental Health Treatment Plan is not considered a referral, and a referral for mental health services under Better Access should be in writing (signed and dated by the referring practitioner [which can be by an electronic signature]) and include:

• the patient's name, date of birth and address;
• the patient's symptoms or diagnosis;
• a list of any current medications;
• the number of services the patient is being referred for; and
• a statement about whether the patient has had a Mental Health Treatment Plan or a Psychiatrist Assessment and Management Plan prepared. 

A referral should include all the above details, and any additional information outlined in AN.15.6 to assist with any auditing undertaken by the Department of Health, Disability and Ageing. Eligible GPs and eligible PMPs who provide focussed psychological strategies services do so as part of an arrangement for the treatment of an assessed mental health disorder under a Mental Health Treatment Plan. Where appropriate, and with the patient's agreement, a copy of the Mental Health Treatment Plan can be attached to the referral.

Use of referrals across different calendar years

If a patient has not used all their psychological therapy services and/or focussed psychological strategies services covered by a referral within the calendar year, it is not necessary to obtain a new referral for the "unused" services. However, any "unused" services received from 1 January in the following year under that referral will count as part of the total services for which the patient is eligible in that calendar year.

When a patient has used all of their referred services, they will need to obtain a new referral from either their GP or PMP at their MyMedicare registered practice or by their usual medical practitioner if they are eligible for further services.

It is not necessary to have a new Mental Health Treatment Plan and/or Psychiatrist Assessment and Management Plan prepared each calendar year in order to access a new referral(s) for psychological therapy services and/or focussed psychological strategies services. A Mental Health Treatment Plan or a Psychiatrist Assessment and Management Plan does not expire. A new Mental Health Treatment Plan or a Psychiatrist Assessment and Management Plan should not be created unless exceptional circumstances exist. An exceptional circumstance may be where the patient has had a significant change to their mental health or the treating practitioner is unable to obtain a copy of their Mental Health Treatment Plan or Psychiatrist Assessment and Management Plan.

Patients continue to be eligible for benefits for psychological therapy services and/or focussed psychological strategies services while they are being managed under a Mental Health Treatment Plan and/or a Psychiatrist Assessment and Management Plan as long as the need for eligible services continues to be recommended. However, patients will only receive a Medicare benefit for psychological therapy services and/or focussed psychological strategies services by eligible allied health professionals if they obtained a referral from a GP or PMP at their MyMedicare registered practice or by their usual medical practitioner.

Receipt of referral

The treating eligible allied health professional providing the relevant treatment service (refer to explanatory notes MN.6.2 – Provision of Psychological Therapy and MN.7.4 – Provision of Focussed Psychological Strategies) must be in receipt of the referral at the first consultation. The treating eligible allied health professional must also retain the referral for a period of 2 years (24 months) from the date the first treatment service was rendered. For more information on record keeping and reporting requirements, refer to explanatory note AN.0.78 – Better Access Initiative.

Further information

For further information on the Better Access Initiative, refer to explanatory note AN.0.78 – Better Access Initiative.

For further information about Medicare Benefits Schedule items, please visit the MBS online website at www.health.gov.au/mbsonline.

Further information is available for providers from the Services Australia provider enquiry line on 132 150.

If you are a patient seeking advice about Medicare services, patient benefits, or your Medicare claims, please contact Services Australia on the Medicare General enquiry line on 132 011.