Eligibility for health professionals

If you’re applying for a Medicare provider number online you must understand your legislative requirements:

• You must apply for a unique provider number for each place of practice and profession you practise in.
• You can apply for an additional provider number for a different location or at the same location.
• You can’t claim a Medicare benefit until we’ve issued your provider number for that location.
• You can’t use anyone else’s Medicare provider number.
• You’re not eligible to claim Medicare benefits if we’ve suspended your membership or registration or if it has expired.
• You’re not eligible if your membership level has changed.
• If you don’t have access to Medicare, you must let patients know before you treat them that they won’t get Medicare benefits for your services.

To provide a service that gets a Medicare benefit, you as a health professional must:

• have a Medicare provider number for each practice location
• meet eligibility requirements set out in the Health Insurance Act 1973 or the relevant legislation relating to your specific health profession
• have been advised in writing that you’re eligible to access Medicare benefits for your services.

If you don’t meet these requirements, you can still practise medicine. You still have to satisfy the requirements set out by your registration body. You can’t claim a Medicare benefit for your services.

You must let patients know they won’t get a Medicare benefit before you provide a service to them. It’s an offence to provide a service without doing this.

You can’t access full Medicare benefits until you meet the general practitioner (GP) and specialist eligibility requirements. Until then, you’ll have limited access to Medicare benefits. As an intern, registrar or trainee, you can still get a Medicare provider number.

To satisfy section 19AA of the Health Insurance Act 1973 and be eligible for a Medicare provider number, you must be one of the following::

• vocationally recognised as a specialist, consultant physician or specialist general practitioner
• registered on the Vocational Register with general registration with the Australian Health Practitioner Regulation Agency (Ahpra)
• registered in an approved placement under section 3GA of the Act
• first registered before 1 November 1996 - some exclusions apply - you can find more information on the Federal Register of Legislation website
• a temporary resident doctor with an exemption under section 19AB of the Act, working according to that exemption.

You can claim Medicare benefits if you meet the general eligibility requirements. You also need to be:

• registered with and satisfy the Registration Standards of the Nursing and Midwifery Board of Australia. Read more about the guidelines on the Nursing and Midwifery Board of Australia website
• endorsed as a nurse practitioner or be an endorsed midwife who holds an endorsement for scheduled medicines
• working in private practice or in a public facility that has an exemption under subsection 19(2) of the Health Insurance Act 1973.

To claim Medicare benefits, allied health professionals must:

• meet the qualification requirements set out in the Health Insurance (Allied Health Services) Determination 2014
• be registered with Ahpra or a respective board or organisation
• be recognised as an allied health professional in their field by us
• be in private practice
• be working in a private capacity.

An allied health professional is also eligible for registration under the allied health professional initiative if they’re employed by an Aboriginal and Torres Strait Islander Community Controlled Health Service, or a state or territory clinic that has an exemption under subsection 19(2) of the Act.

Allied health professionals who may qualify include:

• Aboriginal health workers
• audiologists
• chiropractors
• diabetes educators
• dietitians
• exercise physiologists
• mental health nurses
• occupational therapists
• orthoptists
• osteopaths
• physiotherapists
• podiatrists
• psychologists
• social workers
• speech pathologists.

To claim Medicare benefits, dental practitioners must:

• meet the qualification requirements set out in the Health Insurance (Dental Services) Determination 2007
• be registered with Ahpra or a respective board or organisation
• be recognised as a dental practitioner in their field by us
• be in private practice
• be working in a private capacity.

Dental prosthetists can register for a Medicare provider number but can’t use their provider number for Medicare billing.

To claim Medicare benefits, optometrists must:

• meet the qualification requirements set out in the Health Insurance (Optometric Services) Determination 2016
• be registered with Ahpra or a respective board or organisation
• be recognised as an optometrist by us
• be in private practice
• be working in a private capacity.