Contents
                       1    Name of Determination [see Note 1]                                                     3
                       2    Commencement                                                                                 3
                       3    Definitions                                                                                          3
                       4    Dental services                                                                                   4
                       5    Monetary limit on medicare benefits                                                     4
                       6    Patient eligibility                                                                                 5
                       7    Effect of election to claim private health insurance for a dental service     5
                       8    Application of items — dental services provided by eligible providers to eligible patients 5
                       9    Referral                                                                                              5
                      10    Quotation for dental services and reporting                                            6
                      11    Purpose of service                                                                              6
                      12    Limitation on items — dentures and denture components                       6
                      13    Limitation on number of certain services                                               7
                      14    Limitation on provision of certain services                                              8
                      15    Application of item 85433                                                                    8
                      16    Application of item 85455                                                                    8
                      17    Limitation on items 85521 and 85531                                                   8
                      18    Application of item 85572                                                                    8
                      19    Application of items 85733, 86733 and 87733                                        9
                      20    Application of item 86433                                                                    9
                      21    Application of item 86455                                                                    9
                      22    Limitation on items 86521 and 86531                                                   9
                      23    Application of item 86572                                                                    9
Schedule 1            Dental services and fees                                                                10
Part 1                     Services provided by eligible dentists                                                 10
Part 2                     Services provided by eligible dental specialists                                    19
Part 3                     Services provided by eligible dental prosthetists                                   30
Schedule 2            Specialties                                                                                     33
Notes                                                                                                                             34
1Â Â Â Â Â Â Â Â Â Â Â Â Â Name of Determination [see Note 1]
               This Determination is the Health Insurance (Dental Services) Determination 2007.
2Â Â Â Â Â Â Â Â Â Â Â Â Â Commencement
               This Determination commences on 1 November 2007.
3Â Â Â Â Â Â Â Â Â Â Â Â Â Definitions
               In this Determination:
Act means the Health Insurance Act 1973.
dental service means a dental service mentioned in Schedule 1.
eligible dental prosthetist means an individual:
               (a)   who is registered or entitled to practice as a dental prosthetist under a law of a State or Territory; and
              (b)   whose registration or entitlement to practice as a dental prosthetist entitles the individual to provide services to which any of the items mentioned in Part 3 of Schedule 1 apply; and
               (c)   whose name is entered in the register, kept by the Medicare Australia CEO, of dental prosthetists who can provide services to which any of the items mentioned in Part 3 of Schedule 1 apply.
eligible dental specialist means a person:
               (a)   who is registered or licensed to practice under a law of a State or Territory in a specialty mentioned in Schedule 2; and
              (b)   whose name is entered in the register, kept by the Medicare Australia CEO, of dental specialists who can provide services to which any of the items mentioned in Part 2 of Schedule 1 apply.
eligible dentist means a dental practitioner whose name is entered in the register, kept by the Medicare Australia CEO, of dental practitioners who can provide services to which any of the items mentioned in Part 1 of Schedule 1 apply.
eligible patient has the meaning given by section 6.
GP management plan means a plan to which item 721 or 725 of the general medical services table applies.
multidisciplinary care plan has the meaning given by subrule 36 (2) of the general medical services table.
relevant provisions means all provisions, relating to professional services or to medical services, of the Act and regulations made under the Act, and the National Health Act 1953 and regulations made under that Act.
team care arrangements means team care arrangements to which item 723 or 727 of the general medical services table applies.
Note Unless a contrary intention appears, an expression used in this Determination has the same meaning as in the Health Insurance Act 1973 — see section 13 of the Legislative Instruments Act 2003.
4Â Â Â Â Â Â Â Â Â Â Â Â Â Dental services
               A dental service provided in accordance with this Determination is to be treated, for the relevant provisions, as if:
               (a)   it were both a professional service and a medical service; and
              (b)   there were an item in the general medical services table that:
                         (i)   related to the service; and
                        (ii)   specified for the service a fee for each State, being the fee mentioned in the item in Schedule 1 for the service.
Note For this Determination, an internal Territory is deemed to form part of the State of New South Wales — see subsection 3C (7) of the Act.
5Â Â Â Â Â Â Â Â Â Â Â Â Â Monetary limit on medicare benefits
        (1)  For subsection 3C (2A) of the Act, the total of all amounts of medicare benefit paid or payable for dental services provided to a person in a relevant 2 year period must not exceed $4 250.
        (2)  In this section:
relevant 2 year period, for a person, has the meaning given by subsections (3) and (4).
        (3)  If:
               (a)   a person received a dental service on or after 1 November 2007; and
              (b)   the service is the first dental service that the person has received on or after 1 November 2007;
the calendar year in which the person received that first dental service and the following calendar year is a relevant 2 year period for the person.
        (4)  After that relevant 2 year period, each calendar year in which the person receives a dental health service and the following calendar year is a relevant 2 year period for the person unless the first mentioned year is already part of a relevant 2 year period because of a previous application of this subsection.
Example 1
A person who first receives a dental service on 25 November 2007 will be eligible for not more than $4 250 in medicare benefits for all dental services provided to the person in 2007 and 2008.
A further relevant 2 year period commences for that person in the calendar year when the person first receives a dental service on or after 1 January 2009.
Example 2
A person who first receives a dental service on 15 January 2008 will be eligible for not more than $4 250 in medicare benefits for all dental services provided to the person in 2008 and 2009.
A further relevant 2 year period commences for the person in the calendar year when the patient first receives a dental service on or after 1 January 2010.
6Â Â Â Â Â Â Â Â Â Â Â Â Â Patient eligibility
               A person is an eligible patient if:
               (a)   the person has either:
                         (i)   a GP management plan and team care arrangements in place; or
                        (ii)   a multidisciplinary care plan to which item 731 of the general medical services table applies; and
              (b)   his or her oral health is impacting on, or is likely to impact on, his or her general health; and
               (c)   the person has been referred for a dental service under section 9; and
              (d)   the person is not an admitted patient of a hospital.
7Â Â Â Â Â Â Â Â Â Â Â Â Â Effect of election to claim private health insurance for a dental service
               An item in Schedule 1 applies to a dental service only if a private health insurance benefit has not been claimed for that service.
8             Application of items — dental services provided by eligible providers to eligible patients
        (1)  An item in Part 1 of Schedule 1 applies only to a dental service provided by an eligible dentist to an eligible patient.
        (2)  An item in Part 2 of Schedule 1 applies only to a dental service provided by an eligible dental specialist to an eligible patient.
        (3)  An item in Part 3 of Schedule 1 applies only to a dental service provided by an eligible dental prosthetist to an eligible patient.
9Â Â Â Â Â Â Â Â Â Â Â Â Â Referral
        (1)  A general practitioner may refer an eligible patient for a dental service only to:
               (a)   an eligible dentist; or
              (b)   an eligible dental prosthetist, if the patient:
                         (i)   has no natural teeth and requires only dental prosthetic services; or
                        (ii)   requires only repairs or maintenance to an existing denture.
        (2)  A referral by a general practitioner must be made in the form published by the Department and described as ‘Referral Form for Dental Services under Medicare’, as existing on 1 November 2007, or a form that substantially complies with that form.
Note The form is available on the internet — see http://www.health.gov.au.
        (3)  An eligible dentist who has provided a dental service to an eligible patient referred to the eligible dentist under this subsection or subsection (1), (4) or (5) may refer the patient to an eligible dentist, an eligible dental specialist or an eligible dental prosthetist for an additional dental service.
        (4)  An eligible dental specialist who has provided a dental service to an eligible patient referred to the eligible dental specialist under this subsection or subsection (3) may refer the patient to an eligible dentist, an eligible dental specialist or an eligible dental prosthetist for an additional dental service.
        (5)  An eligible dental prosthetist who has provided a dental service to an eligible patient referred to the eligible dental prosthetist under this subsection or subsection (1), (3) or (4) may refer the patient to an eligible dentist or an eligible dental prosthetist for an additional dental service.
10Â Â Â Â Â Â Â Â Â Â Â Quotation for dental services and reporting
        (1)  This section applies if:
               (a)   an eligible dentist, an eligible dental specialist or an eligible dental prosthetist performs an initial examination and assessment of an eligible patient, including consideration of any diagnostic tests; and
              (b)   provides a course of treatment to the patient.
        (2)  An item in Schedule 1 applies to a dental service included in the course of treatment only if, before beginning the course of treatment, the eligible dentist, eligible dental specialist or eligible dental prosthetist:
               (a)   gave to the eligible patient, in writing:
                         (i)   a plan of the course of treatment; and
                        (ii)   a quotation for each dental service and each other service (if any) in the plan; and
              (b)   gave a copy or written summary of the plan to the general practitioner who referred the patient for dental services.
11Â Â Â Â Â Â Â Â Â Â Â Purpose of service
        (1)  An item in Schedule 1 applies to a dental service only if the primary purpose of the service is to improve the oral health or function of the eligible patient.
        (2)  An item in Schedule 1 does not apply to a dental service if the primary purpose of the service is to improve the appearance of the eligible patient.
        (3)  An item in Schedule 1 applies to a dental service if the primary purpose of the service is to improve the oral health or function of the eligible patient and another purpose of the service is to improve the patient’s appearance.
12           Limitation on items — dentures and denture components
        (1)  For any particular eligible patient, a set of dentures applies not more than:
               (a)   once in 8 years; or
              (b)   if exceptional circumstances exist in relation to the patient — twice in 8 years.
        (2)  In this section:
exceptional circumstances exist in relation to an eligible patient if:
               (a)   an eligible dentist, an eligible dental specialist or an eligible dental prosthetist is satisfied that there has been a significant change in the clinical condition of the patient that necessitates a new set of dentures for the patient; or
              (b)   the existing dentures of the patient have been irreparably damaged or lost.
set of dentures means:
               (a)   complete maxillary and mandibular dentures under item 85719, 86719 or 87719; or
              (b)   a complete or partial maxillary denture under item 85711, 85721, 85727, 86711, 86721, 86727, 87711, 87721 or 87727; or
               (c)   a complete or partial mandibular denture under item 85712, 85722, 85728, 86712, 86722, 86728, 87712, 87722 or 87728; or
              (d)   both:
                         (i)   a complete or partial maxillary denture under any of the items mentioned in paragraph (b); and
                        (ii)   a complete or partial mandibular denture under any of the items mentioned in paragraph (c).
13Â Â Â Â Â Â Â Â Â Â Â Limitation on number of certain services
               For any particular eligible patient, an item mentioned in column 2 of the following table is applicable to a service not more than the number of times mentioned in column 3 of the table in the period mentioned in column 4 of the table.
Item | Item of service | Number of times | Period |
1 | 85123, 85311, 85314, 85322, 85323, 85324, 86123, 86311, 86314, 86322, 86323, 86324 | 1 | 1 day |
2 | 85927, 86927 | 1 | 3 months |
3 | 85111, 85114, 85121, 86111, 86114, 86121 | 1 | 6 months |
4 | 85039, 85047, 85131, 85141, 85221, 85225, 85245, 85433, 86036, 86039, 86047, 86131, 86141, 86221, 86225, 86245, 86433 | 1 | 12 months |
5 | 85753, 86753, 87753 | 1 | 24 months |
6 | 85963, 85964, 86963, 86964 | 1 | 36 months |
7 | 85222, 86222 | 2 | 1 day |
8 | 85115, 85213, 85234, 85986, 86115, 86213, 86234, 86235, 86986 | 2 | 12 months |
9 | 85013, 85572, 86013, 86572 | 3 | 3 months |
10 | 85458, 86458 | 3 | 12 months |
11 | 85231, 85232, 85233, 85971, 86231, 86232, 86233, 86971 | 4 | 12 months |
12 | 85771, 86771, 87771 | 5 | 3 months |
13 | 85022, 86022 | 6 | 1 day |
14Â Â Â Â Â Â Â Â Â Â Â Limitation on provision of certain services
               For any particular eligible patient, an item mentioned in column 2 of the following table is applicable to a service provided by a particular eligible dentist, eligible dental specialist or eligible dental prosthetist not more than once in the period mentioned in column 3 of the table.
Item | Item of service | Period |
1 | 85012, 86012 | 6 months |
2 | 86015, 86038, 86082 | 12 months |
3 | 85011, 87011 | 24 months |
15Â Â Â Â Â Â Â Â Â Â Â Application of item 85433
               For any particular eligible patient, item 85433 does not apply to a service provided to the patient on a day if a service described in item 85431, 85432, 85434, 85436, 85437 or 85438 is provided to the patient on the day.
16Â Â Â Â Â Â Â Â Â Â Â Application of item 85455
               For any particular eligible patient, item 85455 does not apply to a service provided to the patient on a day if a service described in item 85415, 85416, 85417 or 85418 is provided to the patient on the day.
17Â Â Â Â Â Â Â Â Â Â Â Limitation on items 85521 and 85531
               For any particular eligible patient, any combination of items 85521 and 85531 is applicable to not more than 5 services provided to the patient on a day.
18Â Â Â Â Â Â Â Â Â Â Â Application of item 85572
               For any particular eligible patient, item 85572 does not apply to a service provided to the patient on a day if a service described in any of items 85411 to 85418 or items 85431 to 85458 is provided to the patient on the day.
19Â Â Â Â Â Â Â Â Â Â Â Application of items 85733, 86733 and 87733
        (1)  For any particular eligible patient, item 85733 applies to the addition of no more than 12 teeth to a base provided to the patient under item 85721, 85722, 85727 or 85728.
        (2)  For any particular eligible patient, item 86733 applies to the addition of no more than 12 teeth to a base provided to the patient under item 86721, 86722, 86727 or 86728.
        (3)  For any particular eligible patient, item 87733 applies to the addition of no more than 12 teeth to a base provided to the patient under item 87721, 87722, 87727 or 87728.
20Â Â Â Â Â Â Â Â Â Â Â Application of item 86433
               For any particular eligible patient, item 86433 does not apply to a service provided to the patient on a day if a service described in item 86431, 86432, 86434, 86436, 86437 or 86438 is provided to the patient on the day.
21Â Â Â Â Â Â Â Â Â Â Â Application of item 86455
               For any particular eligible patient, item 86455 does not apply to a service provided to the patient on a day if a service described in item 86415, 86416, 86417 or 86418 is provided to the patient on the day.
22Â Â Â Â Â Â Â Â Â Â Â Limitation on items 86521 and 86531
               For any particular eligible patient, any combination of items 86521 and 86531 is applicable to not more than 5 services provided to the patient on a day.
23Â Â Â Â Â Â Â Â Â Â Â Application of item 86572
               For any particular eligible patient, item 86572 does not apply to a service provided to the patient on a day if a service described in any of items 86411 to 86418 or items 86431 to 86458 is provided to the patient on the day.