Commonwealth Numbered Acts

HEALTH INSURANCE AMENDMENT ACT (No. 2) 1978 No. 133 of 1978 - SECT 10

10. (1) Section 11 of the Principal Act is repealed and the following section
substituted: Increased fee in complex cases
'' 11. (1) Where-

   (a)  a claim for a Commonwealth medical benefit in respect of a
        professional service-

        (i)    is referred by a registered medical benefits organization to
               the Department to be dealt with under this section; or

        (ii)   is lodged with the Department by the person by whom, or on
               whose behalf, the professional service was rendered; and

   (b)  there is forwarded with, or included in, the claim a statement by the
        person by whom, or on whose behalf, the professional service was
        rendered that the service was of unusual length or complexity, the
        Permanent Head shall deal with the claim in accordance with the
        succeeding provisions of this section.

'' (2) Where the Permanent Head considers that the professional service
referred to in the claim is of unusual length or complexity, the Permanent
Head shall-

   (a)  if the Permanent Head considers that the service is of a kind in
        respect of which an increased fee may be fixed in accordance with
        principles furnished to the Permanent Head under paragraph (b) of this
        sub-section or under sub-section 12 (5)-fix an increased fee for that
        service, in accordance with those principles, for the purposes of this
        section; or

   (b)  in any other case-refer to the Medical Benefits Advisory Committee for
        its consideration and recommendation the question whether the fee
        specified in the item that relates to that service should, for the
        purpose of calculating the Commonwealth medical benefit in respect of
        that service, be increased, having regard to the unusual features of
        that service, and, if it is to be increased, what principles are to be
        followed in fixing the amount of the increased fee for that service
        for the purposes of this section.

'' (3) Where the Permanent Head receives a recommendation of the Committee
under paragraph (2) (b) in favour of an increased fee for a professional
service, the Permanent Head may fix an increased fee for that service, in
accordance with the principles set out in that recommendation, for the
purposes of this section.

'' (4) Where an increased fee is fixed for a professional service for the
purposes of this section, the amount of the Commonwealth medical benefit in
respect of the service shall be calculated as if the increased fee so fixed
were set out in the item that relates to the service.

'' (5) Where the Permanent Head, in relation to a claim referred to in
sub-section (1)-

   (a)  fixes an increased fee for the professional service to which the claim
        relates; or

   (b)  forms the opinion that the professional service to which the claim
        relates is not of unusual length or complexity, the Permanent Head
        shall, by notice in writing-

   (c)  inform the claimant; and

   (d)  where the claim was referred to the Department by a registered medical
        benefits organization-inform that organization, accordingly.

'' (6) This section does not apply in relation to a claim for a Commonwealth
medical benefit in respect of a professional service covered by an item that
is expressed to relate to a professional attendance by a participating
optometrist.''.

(2) Where a claim for a medical benefit was received by the Health Insurance
Commission under section 11 of the Health Insurance Act 1973 but was not
finally dealt with by the Commission in accordance with that section before
the commencement of this section, then, after the commencement of this
section-

   (a)  the Permanent Head shall deal with the claim as if it were a claim for
        a Commonwealth medical benefit received by him under section 11 of the
        Health  Insurance Act 1973 ;

   (b)  where the claim was referred by the Health Insurance Commission to the
        Medical Benefits Advisory Committee-that Committee shall deal with the
        claim as if it were a claim for a Commonwealth medical benefit
        referred to it by the Permanent Head in accordance with that section;
        and

   (c)  the amount of the medical benefit to which the claim relates shall be
        calculated by reference to any increased fee fixed with respect to the
        claim by the Permanent Head.