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									Health Insurance (Professional
Services Review) Regulations 1999
Statutory Rules 1999 No. 258 as amended

made under the

Health Insurance Act 1973

This compilation was prepared on 4 September 2012
taking into account amendments up to SLI 2012 No. 212

Prepared by the Office of Legislative Drafting and Publishing,
Attorney-General’s Department, Canberra
Contents




                                                                    Page


Contents
Part 1            Introductory
              1   Name of Regulations [see Note 1]                     3
              2   Commencement                                         3
              3   Definition                                           3

Part 2            Adequate and contemporaneous
                  records
              4   Purpose of this Part                                 4
              5   An adequate record                                   4
              6   A contemporaneous record                             4

Part 3            Prescribed pattern of services
              7   Definition                                           5
              8   Purpose of this Part                                 5
              9   Practitioners affected by these Regulations          5
             10   Circumstances constituting a prescribed pattern      5
             11   Exceptional circumstances                            6

Part 4            Appropriate regulatory and other
                  bodies for referral of professional
                  issues
             12   Appropriate body for non-compliance with
                  professional standards                               7
Schedule 1        Regulatory and other bodies to which
                  non-compliance by general practitioner may be
                  referred                                             8
Schedule 2        Regulatory and other bodies to which
                  non-compliance by practitioner other than a
                  general practitioner may be referred                 9

Notes                                                                 10




2             Health Insurance (Professional Services Review)
                             Regulations 1999
                                                  Introductory          Part 1


                                                                 Regulation 3




Part 1                    Introductory

1        Name of Regulations [see Note 1]
         These Regulations are the Health Insurance (Professional
         Services Review) Regulations 1999.

2        Commencement
         These Regulations commence on 1 November 1999.

3        Definition
         In these Regulations:
         Act means the Health Insurance Act 1973.
         Note Several other words and expressions used in these Regulations have
         the meaning given by the Act. For example:
          adequate and contemporaneous records (section 81)
          Committee (section 81)
          general medical services table (section 3)
          general practitioner (section 3)
          inappropriate practice (section 81)
          medical practitioner (section 3)
          person under review (section 81)
          practitioner (section 81)
          profession (section 81)
          referred services (section 81)
          relevant period (section 106KA)
          service (section 81).




               Health Insurance (Professional Services Review)              3
                              Regulations 1999
Part 2         Adequate and contemporaneous records


Regulation 4




Part 2                    Adequate and
                          contemporaneous records

4        Purpose of this Part
         This Part sets out the standards to be met in order that a
         practitioner’s records of the rendering or initiation of services
         be adequate and contemporaneous records.
         Note See subsection 82 (3) of the Act for the significance of adequate and
         contemporaneous records.


5        An adequate record
          For the definition of adequate and contemporaneous records in
          section 81 of the Act, the standard to be met in order that a
          record of service rendered or initiated be adequate is that:
         (a) the record clearly identify the name of the patient; and
         (b) the record contain a separate entry for each attendance by
               the patient for a service and the date on which the service
               was rendered or initiated; and
         (c) each entry provide clinical information adequate to
               explain the type of service rendered or initiated; and
         (d) each entry be sufficiently comprehensible that another
               practitioner, relying on the record, can effectively
               undertake the patient’s ongoing care.

6        A contemporaneous record
          For the definition of adequate and contemporaneous records in
          section 81 of the Act, the standard to be met in order that a
          record of a service rendered or initiated be contemporaneous, is
          that record must be completed:
         (a) at the time the practitioner rendered or initiated the
               service; or
         (b) as soon as practicable after the service was rendered or
               initiated by the practitioner.


4              Health Insurance (Professional Services Review)
                              Regulations 1999
                                  Prescribed pattern of services             Part 3


                                                                   Regulation 10




Part 3                    Prescribed pattern of services

7        Definition
         For this Part:
         professional attendance means a service of a kind mentioned
         in group A1, A2, A5, A6, A7, A9, A11, A13, A14, A15, A16,
         A17, A18, A19, A20, A21, A22 or A23 of Part 2 of the general
         medical services table.

8        Purpose of this Part
         This Part prescribes the circumstances in which referred
         services constitute a prescribed pattern of services for
         Part VAA of the Act.
         Note Section 106KA of the Act provides that conduct of a person under
         review in connection with rendering or initiating services that constitute a
         prescribed pattern of services may be taken to be inappropriate practice.


9        Practitioners affected by these Regulations
          For subsection 106KA (3) of the Act, the following groups of
          practitioners in the profession of medicine are groups to which
          these Regulations apply:
         (a) general practitioners;
         (b) other medical practitioners rendering professional
               attendances.

10       Circumstances constituting a prescribed pattern
         The circumstance in which services that are professional
         attendances constitute a prescribed pattern of services is that 80
         or more such services are rendered on each of 20 or more days
         in a 12 month period.




               Health Insurance (Professional Services Review)                   5
                              Regulations 1999
Part 3          Prescribed pattern of services


Regulation 11



11       Exceptional circumstances
          For subsection 106KA (5) of the Act, the following
          circumstances are declared as constituting exceptional
          circumstances:
         (a) an unusual occurrence causing an unusual level of need
               for professional attendances;
         (b) an absence of other medical services, for patients of the
               person under review during the relevant period, having
               regard to:
                 (i) the location of the practice of the person under
                     review; and
                (ii) characteristics of the patients of the person under
                     review.




6               Health Insurance (Professional Services Review)
                               Regulations 1999
 Appropriate regulatory and other bodies for referral of professional           Part 4
                                                               issues


                                                                        Regulation 12




Part 4                        Appropriate regulatory and
                              other bodies for referral of
                              professional issues

12         Appropriate body for non-compliance with
           professional standards
     (1) For paragraph 106XB (3) (a) of the Act, the appropriate body is
          a body specified in column 2 of an item in Schedule 1 that, for
          a general practitioner:
         (a) is responsible for registering general practitioners or for
               regulating the practice of the profession; and
         (b) has the power to take action against the general
               practitioner in relation to the practitioner’s failure to
               comply with professional standards.
     (2) For paragraph 106XB (3) (b) of the Act, the appropriate body
          is a body specified in column 2 of an item in Schedule 2 that,
          for a practitioner other than a general practitioner:
         (a) is responsible for registering practitioners for practice in
               the profession or specialty to which the practitioner
               belongs or for regulating the practice of that profession or
               specialty; and
         (b) has the power to take action against the practitioner in
               relation to the practitioner’s failure to comply with
               professional standards.




                  Health Insurance (Professional Services Review)                   7
                                 Regulations 1999
Schedule 1      Regulatory and other bodies to which non-compliance by general
                practitioner may be referred




Schedule 1                Regulatory and other bodies
                          to which non-compliance by
                          general practitioner may be
                          referred
                          (subregulation 12 (1))



 Item   Body

    1 Medical Board of Australia
    2 General Practice Recognition Appeal Committee
      General Practice Recognition Eligibility Committee
      Royal Australian College of General Practitioners
    3 Australian General Practice Accreditation Limited
      Quality Practice Accreditation Pty Ltd




8              Health Insurance (Professional Services Review)
                              Regulations 1999
          Regulatory and other bodies to which non-compliance by        Schedule 2
       practitioner other than a general practitioner may be referred




Schedule 2                    Regulatory and other bodies
                              to which non-compliance by
                              practitioner other than a
                              general practitioner may be
                              referred
                              (subregulation 12 (2))
Item    Body

  1 Chiropractic Board of Australia
  2 Dental Board of Australia
  3 Department of Human Services
  4 Medical Board of Australia
  5 Nursing and Midwifery Board of Australia
  6 Optometry Board of Australia
  7 Osteopathy Board of Australia
  8 Physiotherapy Board of Australia
  9 Podiatry Board of Australia




                  Health Insurance (Professional Services Review)               9
                                 Regulations 1999
Notes to the Health Insurance (Professional Services Review) Regulations 1999


Table of Instruments




Notes to the Health Insurance (Professional
Services Review) Regulations 1999
Note 1
The Health Insurance (Professional Services Review) Regulations 1999
(in force under the Health Insurance Act 1973) as shown in this
compilation comprise Statutory Rules 1999 No. 258 amended as
indicated in the Tables below.

Table of Instruments

Year and           Date of               Date of                   Application,
number             notification          commencement              saving or
                   in Gazette or FRLI                              transitional
                   registration                                    provisions
1999 No. 258       27 Oct 1999           1 Nov 1999
1999 No. 346       22 Dec 1999           1 Jan 2000                —
2001 No. 45        16 Mar 2001           16 Mar 2001               —
2006 No. 199       28 July 2006 (see     29 July 2006              —
                   F2006L02427)
2011 No. 120       30 June 2011 (see     1 July 2011               —
                   F2011L01364)
2012 No. 212       3 Sept 2012 (see      4 Sept 2012               —
                   F2012L01822)




10               Health Insurance (Professional Services Review)
                                Regulations 1999
           Notes to the Health Insurance (Professional Services Review) Regulations 1999


                                                                            Table of Amendments




Table of Amendments
ad. = added or inserted             am. = amended      rep. = repealed   rs. = repealed and substituted

Provision affected                           How affected
Part 1
Note 1 to r. 3 .......................       am. 1999 No. 346
                                             rep. 2012 No. 212
Note 2 to r. 3 .......................       ad. 1999 No. 346
                                             rep. 2012 No. 212
Note to r. 3 ..........................      ad. 2012 No. 212
Part 2
Note to r. 4 ..........................      am. 2012 No. 212
Part 3
Part 3 ..................................    ad. 1999 No. 346
R. 7 .....................................   ad. 1999 No. 346
                                             am. 2001 No. 45; 2006 No. 199; 2012 No. 212
Note to r. 7 ..........................      rep. 2012 No. 212
R. 8 .....................................   ad. 1999 No. 346
R. 9 .....................................   ad. 1999 No. 346
R. 10 ...................................    ad. 1999 No. 346
R. 11 ...................................    ad. 1999 No. 346
Note to r. 11 ........................       rep. 2012 No. 212
Part 4
Part 4 ..................................    ad. 2006 No. 199
R. 12 ...................................    ad. 2006 No. 199
                                             am. 2012 No. 212
Schedule 1
Schedule 1 ..........................        ad. 2006 No. 199
                                             am. 2012 No. 212
Schedule 2
Schedule 2 ..........................        ad. 2006 No. 199
                                             am. 2011 No. 120
                                             rs. 2012 No. 212




                           Health Insurance (Professional Services Review)                           11
                                          Regulations 1999

								
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