Part 1—Preliminary
1 Name of Rules
These Rules are the Dental Benefits Rules 2014.
2A Authority
These Rules are made under the Dental Benefits Act 2008.
4 Definitions
Note: A number of expressions used in these Rules are defined in the Act, including the following:
(a) Chief Executive Medicare;
(b) dental practitioner;
(c) dental provider;
(d) item.
In these Rules:
Act means the Dental Benefits Act 2008.
carer payment has the meaning given by Part 2.5 of the Social Security Act 1991.
dental hygienist means a person who has general registration in the dental hygienists division of the dental profession under a law of a State or Territory.
dental prosthetist means a person who has general registration in the dental prosthetists division of the dental profession under a law of a State or Territory.
dental therapist means a person who has general registration in the dental therapists division of the dental profession under a law of a State or Territory.
disability support pension has the meaning given by Part 2.3 of the Social Security Act 1991.
double orphan pension has the meaning given by Part 2.20 of the Social Security Act 1991.
FTB(A) person has the same meaning as in section 24 of the Act.
FTB recipient has the same meaning as in section 24 of the Act.
medicare number has the same meaning as in section 84 of the National Health Act 1953.
MRCAETS means the Military Rehabilitation and Compensation Act Education and Training Scheme.
Note Military Rehabilitation and Compensation Act Education and Training Scheme 2004 is a legislative instrument.
oral health therapist means a person who has general registration in the oral health therapists division of the dental profession under a law of a State or Territory.
parenting payment has the meaning given by the definition of parenting payment in section 18 of the Social Security Act 1991.
partner has the same meaning as in the Social Security Act 1991.
provider number has the same meaning as in the Health Insurance Regulations 2018.
public sector dental provider means:
(a) a dental provider employed by, contracted to, or providing dental services under an arrangement with:
(i) the Commonwealth; or
(ii) a State; or
(iii) an internal Territory; or
(iv) a local governing body; or
(v) an authority established by a law of the Commonwealth, a law of a State or a law of an internal Territory; or
(b) a dental provider on whose behalf another dental provider provides dental services under an arrangement with a body mentioned in subparagraph (a)(i), (ii), (iii), (iv) or (v).
receive, for disability support pension, parenting payment, special benefit, carer payment and double orphan pension, has the meaning given by section 23 of the Social Security Act 1991.
registered dentist means a dental provider covered by paragraph 6(1)(a) of the Act.
relevantly provided, for a dental service, means provided as a service for which dental benefit is payable under the Act.
special benefit has the meaning given by Part 2.15 of the Social Security Act 1991.
VCES means the Veterans’ Children Education Scheme.
Note: Veterans’ Children Education Scheme is a legislative instrument.
5 Dental Benefits Schedule
For subsection 61(1) of the Act, the Dental Benefits Schedule is set out in Schedule 1.
6 Dental providers
(1) For the purposes of paragraph 6(1)(b) of the Act, a person included in one or more of the following classes of persons is a dental provider in relation to a dental service:
(a) dental hygienists;
(b) dental therapists;
(c) oral health therapists.
Note: A registered dentist is also a dental provider in relation to a dental service (see the definition of dental provider in paragraph 6(1)(a) of the Act).
(2) For the purposes of paragraph 6(2)(b) of the Act, a dental practitioner is not a dental provider in relation to a dental service if the dental practitioner has not been allocated a provider number by the Chief Executive Medicare.
7 Persons eligible to render services on behalf of dental providers
Dental services rendered on behalf of registered dentists
(1) For the purposes of paragraph 7(a) of the Act, a dental service may be rendered on behalf of a registered dentist who is not a public sector dental provider by a person who is included in one or more of the following classes of persons:
(a) dental hygienists;
(b) dental therapists;
(c) dental prosthetists;
(d) oral health therapists.
Dental services rendered on behalf of public sector dental providers
(2) For the purposes of paragraph 7(a) of the Act, a dental service may be rendered on behalf of a public sector dental provider who is a registered dentist by another public sector dental provider.
Part 2—Payment of dental benefits
8 Particulars to be recorded (Act, s 17(2))
Patient billed services
(1) For the payment of dental benefits listed in the Dental Benefits Schedule, the following particulars must be recorded on the account or receipt:
(a) the patient’s name;
(b) the date of the service;
(c) the item number in the Dental Benefits Schedule that corresponds to the service;
(d) the dental provider’s name and provider number;
(e) the amount charged for the service, total amount paid, and any amount outstanding for the service.
Bulk billed services
(2) If there is an assignment of dental benefits for an item under the Dental Benefits Schedule, the following particulars must be recorded on the assignment of benefit form:
(a) the patient’s name;
(b) the date of the service;
(c) the item number in the Dental Benefits Schedule that corresponds to the service;
(d) the dental provider’s name and provider number;
(e) the amount of the dental benefit being assigned to the dental provider.
8AA Dental benefit is not payable unless dental services rendered by appropriate dental providers
For the purposes of subsection 18(1) of the Act, dental benefit is not payable for a dental service specified in an item mentioned in column 1 of an item of the following table unless the condition that the dental service is rendered by, or on behalf of, a dental provider of a kind mentioned in column 2 of that table item is satisfied.
Dental benefit payable for dental services rendered by kinds of dental providers |
Item | Column 1 Item in the Dental Benefits Schedule | Column 2 Dental provider |
1 | Item 88314, 88322, 88323, 88324, 88326, 88351, 88392, 88412, 88415, 88416, 88417, 88418, 88419, 88421, 88455, 88458, 88597, 88721, 88722, 88723, 88724, 88731, 88733, 88736, 88741, 88761, 88762, 88764, 88765, 88766, 88768, 88942 or 88943. | A registered dentist |
2 | Item 88311, 88316, 88384, 88386, 88387, 88411, 88414, 88511, 88512, 88513, 88514, 88515, 88521, 88522, 88523, 88524, 88525, 88531, 88532, 88533, 88534, 88535, 88574, 88575, 88579, 88586 or 88587. | A dental provider of a kind who is: (a) a registered dentist; or (b) a dental therapist; or (c) an oral health therapist. |
Note: This condition does not apply for dental services specified in other items in the Dental Benefits Schedule.
8A Dental benefits not payable unless conditions satisfied (Act, s 18(2))
(1) A dental service rendered in a State or internal Territory by or on behalf of or under an arrangement with a State or internal Territory is not eligible for dental benefits unless:
(a) the State or internal Territory in which the service was performed is mentioned in column 1 of Schedule 2; and
(b) the service is provided on or before the date in column 2 of schedule 2 pertaining to that State or internal Territory.
(2) Despite subrule (1) the Minister may direct that a dental service rendered in a State or internal Territory by or on behalf of or under an arrangement with a State or internal Territory is eligible for dental benefits.
(3) A dental benefit is not payable in respect of a dental service unless, at the time the dental service is rendered, the eligible dental patient to whom the dental service is rendered is an eligible person.
Part 3—Dental benefits vouchers
9 Classes of persons who satisfy the means test (Act, s 24(1)(d))
For paragraph 24(1)(d) of the Act, a person satisfies the means test, in a calendar year, if in the calendar year:
(a) both:
(i) section 23 of the Act applies to the person; and
(ii) the person is receiving any of the following payments:
(A) disability support pension;
(B) parenting payment;
(C) special benefit;
(D) carer payment;
(E) payments made under VCES or MRCAETS, if the person is a person mentioned in paragraph (c), in column 3, of item 2 of the table in subsection 22A(1) of A New Tax System (Family Assistance) Act 1999; or
(b) both:
(i) section 23 of the Act applies to the person; and
(ii) the person’s parent, carer or guardian is receiving parenting payment or double orphan pension for the person; or
(c) both:
(i) section 23 of the Act applies to the person; and
(ii) the person’s partner is receiving parenting payment; or
(d) both:
(i) section 23 of the Act applies to the person; and
(ii) another person is receiving payments under VCES or MRCAETS on behalf of the person where that other person is a person referred to in paragraph (c), in column 3, of item 2 of the table in subsection 22A(1) of A New Tax System (Family Assistance) Act 1999.
10 Issuing more than 1 voucher for a person for a calendar year (Act, s 27 (5))
(1) For the Dental Benefits Schedule, more than 1 voucher may be issued for a person for a calendar year if:
(a) the person is an FTB(A) person for whom there is more than 1 FTB recipient; or
(b) the person has more than 1 parent, carer or guardian who is receiving double orphan pension for the person; or
(c) the person’s voucher has been lost or destroyed, or the person has not received it.
(2) For paragraphs (1)(a) and (b), the Chief Executive Medicare may issue 2 vouchers for the person.
(3) For paragraph (1)(c), the Chief Executive Medicare may issue a replacement voucher if the person asks the Department of Human Services for a replacement voucher, stating whether the voucher was lost, destroyed or not received.
11 When vouchers are not required to be issued (Act, s 29)
(1) The Chief Executive Medicare is not required to issue a voucher for a calendar year for a person who qualifies for the voucher if:
(a) the person has not been assigned a medicare number; or
(b) both:
(i) written consent has not been provided by a person mentioned in sub‑subparagraph (ii)(A) or (B) for the Department of Veterans’ Affairs to provide his or her personal information to the Department of Human Services for use in the administration of this Act; and
(ii) either:
(A) the person is eligible for payments under VCES or MRCAETS; or
(B) another person is receiving payments under VCES or MRCAETS on behalf of the person; or
(c) the person has reached the cap set for the relevant 2 year period.
(2) In this rule:
cap and relevant 2 year period have the meanings given in rule 14.
12 Period of effect of voucher (Act, s 31)
For the Dental Benefits Schedule:
(a) a voucher for the calendar year commencing on 1 January 2014 takes effect on and from that date and remains in effect until the end of 31 December 2014; and
(b) a voucher for a calendar year commencing on 1 January of a subsequent year takes effect at the beginning of 1 January of that year and remains in effect until the end of 31 December of that year.
13 Persons to whom the vouchers are to be issued (Act, s 32(c))
For the Dental Benefits Schedule, a voucher is to be issued:
(a) if an eligible dental patient is receiving youth allowance — to the eligible dental patient; or
(b) if an eligible dental patient is receiving a payment under the ABSTUDY scheme, or another person or an institution is receiving such a payment in respect of the eligible dental patient:
(i) if the eligible dental patient applied for the payment — to the eligible dental patient; or
(ii) if the eligible dental patient’s parent or guardian applied for the payment — to the parent or guardian who made the application; or
(iii) if an institution applied for the payment — to the institution that made the application; or
(c) if an eligible dental patient is an FTB(A) person:
(i) if there is 1 FTB recipient for the person — to the FTB recipient for the person; or
(ii) if there is more than 1 FTB recipient for the person — to the FTB recipient with the highest percentage of care arrangements for the person; or
(iii) if there is more than 1 FTB recipient for the person and the FTB recipients have equal care arrangements for the person — to a maximum of 2 FTB recipients with the most current records of entitlement; or
(d) if an eligible dental patient is receiving a payment mentioned in subparagraph 9(a) — to the eligible dental patient; or
(e) if an eligible dental patient’s parent, carer or guardian is receiving parenting payment for the eligible dental patient — to the parent, carer or guardian receiving the payment; or
(f) if an eligible dental patient’s carer or guardian is receiving double orphan pension for the eligible dental patient:
(i) if there is 1 carer or guardian receiving the pension for the eligible dental patient — to the carer or guardian receiving the pension; or
(ii) if there is more than 1 carer or guardian receiving the pension for the eligible dental patient — to the carer or guardian receiving the pension with the highest percentage of care arrangements for the eligible dental patient; or
(iii) if there is more than 1 carer or guardian receiving the pension for the eligible dental patient and those carers and/or guardians have equal care arrangements for the eligible dental patient — to a maximum of 2 carers or guardians receiving the pension with the most current records of entitlement; or
(g) if an eligible dental patient is a person mentioned in paragraph 9(c) — to the partner receiving the payment; or
(h) if an eligible dental patient is a person mentioned in paragraph 9(d) — to the person receiving the payment on behalf of the eligible dental patient.
Part 4—Other conditions, limitations or restrictions for items
14 Monetary limit on dental benefits (Act s. 62(2)(c))
(1) The total of dental benefit payable in respect of dental services provided to an eligible dental patient must not exceed the specified monetary limit for the relevant 2 year period.
(2) In this rule:
specified monetary limit is the cap.
(3) An eligible dental patient shall be subject to a cap as listed in Schedule 3.
(4) The cap is the maximum amount of dental benefits paid for services listed in the Dental Benefits Schedule provided to the eligible dental patient within a relevant 2 year period referred to in column 1 of Schedule 3.
(5) In this rule:
relevant 2 year period, for an eligible dental patient, has the meaning given by subrules (6), (7), (8) and (9).
(6) If:
(a) an eligible dental patient received a dental service on or after 1 January 2014; and
(b) the dental service is the first dental service that the eligible dental patient has received on or after 1 January 2014;
the calendar year in which the eligible dental patient received that first dental service and the following calendar year is a relevant 2 year period for the eligible dental patient.
(7) Once the limit set by the cap for a relevant 2 year period has been reached the eligible dental patient will not receive any more benefits in that relevant 2 year period.
(8) Once a relevant 2 year period has ended, the first time thereafter that a dental service listed in the Dental Benefits Schedule is rendered to an eligible dental patient it will trigger the commencement of a subsequent relevant 2 year period.
(9) If there is no cap listed in Schedule 3 for the relevant 2 year period in which a service is provided, the cap for the most recent 2 year period listed in that Schedule shall apply.
Example 1
A person who first receives a dental service on 25 January 2014 will be eligible for not more than $1,000 in dental benefits for all dental services provided to the person in 2014 and 2015.
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 2016.
15 Informed financial consent (Act, s 62(2))
(1) An item in the Dental Benefits Schedule applies to a dental service only if a dental provider:
(a) obtains consent to provide the dental service from the eligible dental patient or a person able to consent on his/her behalf and informed financial consent to costs from the person who incurs the dental expenses for that dental service before providing any item in the Dental Benefits Schedule; and then:
(b) records the consent to treatment and costs; and
(c) obtains the appropriate signature or signatures on a patient consent form.
(2) In respect of a dental service where there has been an agreement under section 12 of the Act between the eligible dental patient and the dental provider to assign dental benefits, subrule 15(1) is met if a ‘Bulk Billing Patient Consent Form’ was executed on the same day as the service was provided, or on an earlier day in the same calendar year.
(3) In respect of any dental service, subrule 15(1) is met if a ‘Non‑Bulk Billing Patient Consent Form’ was executed on the same day as the service was provided. For the avoidance of doubt, this subrule does not apply to a service if subrule 15(1) is met under subrule 15(2) in respect of that service.
(4) The patient consent form executed under subrule 15(2) must be made in the form published by the Department and described as the ‘Bulk Billing Patient Consent Form’, as existing on 1 January 2014.
Note: The form is available on the internet – see http://www.health.gov.au/dental
Note: Section 25C of the Acts Interpretation Act 1901 provides that where an Act prescribes a form, then strict compliance with the form is not required and substantial compliance is sufficient.
(5) The patient consent form executed under subrule 15(3) must be made in the form published by the Department and described as the ‘Non‑Bulk Billing Patient Consent Form’, as existing on 1 January 2014.
Note: The form is available on the internet – see http://www.health.gov.au/dental
Note: Section 25C of the Acts Interpretation Act 1901 provides that where an Act prescribes a form, then strict compliance with the form is not required and substantial compliance is sufficient.
(6) Subrules 15(1)(b) and 15(1)(c) do not apply in respect of a dental service if an ‘extenuating circumstance’ applies in respect of that service.
(7) For this rule, extenuating circumstances are as determined in the ‘Ministerial guidelines for the Child Dental Benefits Schedule: Extenuating circumstances for informed financial consent’ as made by the Minister and as amended from time to time.
Note 1: The guidelines are available on the internet – see http://www.health.gov.au/dental
Note 2: Section 60 of the Act provides that despite anything in the Legislation Act 2003, the Rules may make provision in relation to a matter by applying, adopting or incorporating any matter contained in any other instrument or writing as in force or existing from time to time.
16 Clinical records
(1) Eligible dental providers must keep clinical records, including relevant patient consent forms for the provision of all services listed in the Dental Benefits Schedule for a period of four years; and
(2) Where a service in the Dental Benefits Schedule pertains to a particular tooth or teeth, the tooth or teeth must be recorded.
17 Limitation on number of certain services
For any particular eligible dental patient:
(a) an item of the Dental Benefits Schedule 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 | 88311, 88314, 88322, 88323, 88324 | 1 | 1 day |
2 | 88111, 88114, 88121 | 1 | 5 months |
3 | 88942 | 1 | 12 months |
4 | 88221, 88721, 88722 | 1 | 24 months |
5 | 88115, 88213 | 2 | 12 months |
6 | 88013, 88572 | 3 | 3 months |
7 | 88458 | 3 | 12 months |
8 | 88022, 88161, 88575 | 4 | 1 day |
9 | 88768 | 8 | 24 months |
(b) items 88111, 88114 and 88121 must not be provided more than two times per calendar year.
18 Limitation on provision of certain services
For any particular eligible dental patient:
(a) an item of the Dental Benefits Schedule mentioned in column 2 of the following table is applicable to a service provided by a particular eligible dental provider, not more than once in the period mentioned in column 3 of the table:
Item | Item of service | Period |
1 | 88012 | 5 months |
2 | 88011 | 24 months |
(b) item 88012 must not be provided more than two times by a particular eligible dental provider per calendar year.
19 Limitation on Diagnostic Services
For any particular eligible dental patient:
(a) an item listed in Subgroup 1 of Group U0 of the Dental Benefits Schedule:
(i) is applicable to a service once only per day; and
(ii) is not applicable to a service if the service is provided in combination with a service described in any of the other items in the Subgroup on that day that has been relevantly provided;
(b) item 88012 is not applicable to a service if the service is provided within 5 months of a service described in item 88011 being relevantly provided, where both services are provided by the same eligible dental provider.
20 Limitation on Preventive Services
For any particular eligible dental patient:
(a) an item listed in Subgroup 1 of Group U1 of the Dental Benefits Schedule is not applicable to a service if:
(i) the service is provided in combination with a service described in any of the other items in the Subgroup (the second service) on that day; and
(ii) the second service is relevantly provided;
(b) an item listed in Subgroup 3 of Group U1 of the Dental Benefits Schedule is not applicable to a service if the service is provided in respect of the same tooth on the same day as a service described in any of the items 88511 to 88535 is relevantly provided.
21 Limitation on Periodontic Services
For any particular eligible dental patient item 88213 is not applicable to a service if the service is provided in respect of a tooth on the same day as the service described in item 88415 is relevantly provided in respect of the same tooth.
22 Limitation on Oral Surgery
For any particular eligible dental patient:
(a) item 88311 is not applicable to a service if the service is provided on the same day as the service described in item 88314 is relevantly provided;
(b) item 88322 is not applicable to a service if the service is provided on the same day as a service described in either item 88323 or 88324 is relevantly provided;
(c) item 88323 is not applicable to a service if the service is provided on the same day as the service described in item 88324 is relevantly provided;
(d) item 88324 is applicable to a service provided in respect of a multi‑rooted tooth only;
(e) for any tooth, only one of items 88311 to 88326 is applicable to a service provided in respect of that tooth;
(f) items 88384 to 88392 are not applicable to a service if the service is provided in respect of a tooth on any date after any of items 88311 to 88326 has been relevantly provided in respect of the same tooth;
(g) item 88351 is only applicable to a service if the service is provided on the same day as any of items 88384, 88386 or 88387 are relevantly provided.
23 Limitation on Endodontic Services
For any particular eligible dental patient:
(a) item 88412 is applicable once only to a service provided in respect of a particular tooth;
(b) an item in Group U4 of the Dental Benefits Schedule is not applicable to a service if the service is provided in respect of a tooth at any time after item 88412 has been relevantly provided in respect of that same tooth;
(c) item 88415 is applicable once only to a service provided in respect of a particular tooth on a day;
(d) item 88416 is applicable to a service provided in respect of a particular tooth to a maximum of twice on a day;
(e) item 88417 is applicable once only to a service provided in respect of a particular tooth on a day;
(f) item 88418 is applicable to a service provided in respect of a particular tooth up to a maximum of twice on a day;
(g) item 88414 is not applicable to a service provided in respect of a tooth on the same day as the service described in item 88421 is relevantly provided in respect of that tooth;
(h) item 88418 is not applicable to a service provided in respect of a tooth on the same day as the service described in item 88419 is relevantly provided in respect of that tooth;
(i) item 88419 is not applicable to a service provided in respect of a tooth on the same day as any of items 88311 to 88326, 88411 to 88417, 88421, 88455, 88458 or 88511 to 88535 is relevantly provided in respect of that tooth;
(j) item 88421:
(i) is applicable to a service once only per primary tooth; and
(ii) is not applicable to a service if the service described in item 88414 is relevantly provided in respect of the same tooth on the same day;
(k) item 88458 may apply to a service provided on the same day as a service described in either item 88415 or 88416 is relevantly provided but no other item in Group U4 of the Dental Benefits Schedule, other than item 88455, will apply to a service until at least three months has elapsed.
24 Limitation on Restorative Services
For any particular eligible dental patient:
(a) only one of any of items 88511 to 88535 applies to a service provided in respect of a particular tooth on a day;
(b) item 88575:
(i) only applies to a service provided in respect of a tooth if a service described in one of the items 88511 to 88535 has been relevantly provided in respect of that tooth on the same day; and
(ii) may apply to a service provided in respect of a particular tooth up to a maximum of twice on a day;
(c) item 88597:
(i) only applies to a service provided in respect of a particular tooth if a service described in one of the items 88511 to 88535 has been relevantly provided in respect of that tooth on the same day; and
(ii) may apply to a service provided in respect of a particular tooth up to a maximum of twice on a day.
24A Limitation on Denture Bases
For any particular eligible dental patient:
(a) item 88721 does not apply to a service provided within a 6 month period of a service described in item 88723;
(b) item 88722 does not apply to a service provided within a 6 month period of a service described in item 88724;
(c) item 88723 must not be provided more than once;
(d) item 88724 must not be provided more than once.
25 Limitation on Prosthodontics
For any particular eligible dental patient:
(a) item 88731:
(i) only applies to a service provided in respect of a denture base relevantly provided to the patient under item 88721, 88722, 88723 or 88724; and
(ii) applies to a service a maximum of 4 times in respect of each denture base;
(b) item 88733:
(i) only applies to a service provided in respect of a denture base relevantly provided to the patient under item 88721, 88722, 88723 or 88724; and
(ii) applies to a service a maximum of 4 times in respect of each denture base; and
(iii) applies to the fitting of an anterior tooth only;
(c) item 88736:
(i) only applies to a service provided in respect of a denture base relevantly provided to the patient under item 88721, 88722, 88723 or 88724; and
(ii) applies to a service a maximum of 4 times in respect of each denture base;
(d) item 88741 does not apply to a service provided by a particular dental provider if the service is provided within a 12 month period of a service described in item 88721, 88722, 88723 or 88724being relevantly provided by the same dental provider.
26 Application of item 88455
(a) For any particular eligible dental patient, item 88455 does not apply to a service provided in respect of a tooth on a day if a service described in item 88414, 88415, 88416, 88417, 88418 or 88421 is relevantly provided in respect of the same tooth on the day.
(b) For any particular eligible dental patient, item 88455 applies to a service only if a service described in item 88415 or 88416 has been relevantly provided to the patient in the previous three months.
27 Limitation on items 88521 and 88531
(a) For any particular eligible dental patient, any combination of items 88521 and 88531 is applicable to not more than 5 services provided to the patient on a day.
(b) For the maximum of 5 services where it is possible to claim for item 88531 that item should be claimed.
27A Limitation on items 88586 and 88587
For any particular eligible dental patient, only one of either item 88586 or 88587 is applicable for a service provided in respect of a particular tooth on a day.
28 Application of item 88572
For any particular eligible dental patient, item 88572 does not apply to a service provided to the patient on a day if a service described in any of items 88411 to 88418 or items 88421 to 88458 is relevantly provided to the patient on the same day.
29 Application of item 88911
For any particular eligible dental patient, item 88911 is not applicable to a service provided to the patient by a dental provider if another service in the Dental Benefits Schedule is relevantly provided to the patient by the same dental provider on the same day.
Part 5—Application, savings and transitional provisions
Division 1—Amendments made by the Dental Benefits Amendment (Allied Dental Practitioners) Rules 2022
30 Application of amendments
The amendments made by the Dental Benefits Amendment (Allied Dental Practitioners) Rules 2022 apply in relation to the payment of dental benefits for dental services that are rendered on or after 1 July 2022.