Health Insurance (Section 4BA - Pathologist-Determinable Services) Determination 2025

I, Mary Warner, delegate for the Minister for Health and Ageing, make the following Determination.

Dated  23 December 2025

Mary Warner

Contents

1  Name...................................................1

2  Commencement............................................1

3  Authority................................................1

4  Schedules................................................1

5  Definitions...............................................1

6  Services rendered to a patient of a pathologist...........................2

7  Services rendered where a different service was originally requested.............2

8  Services described in items 69316, 69317, 69319, 69494, 69495, 69496, 69497 and 694983

9  A service described in item 72860..................................3

Schedule 1—Repeals 5

Health Insurance (Pathologist-determinable Services) Determination 2015 5

1  Name

  This instrument is the Health Insurance (Section 4BA - Pathologist-Determinable Services) Determination 2025.

2  Commencement

 (1)  Each provision of this instrument specified in column 1 of the table commences, or is taken to have commenced, in accordance with column 2 of the table. Any other statement in column 2 has effect according to its terms.

Note: This table relates only to the provisions of this instrument as originally made. It will not be amended to deal with any later amendments of this instrument.

 (2) Any information in column 3 of the table is not part of this instrument. Information may be inserted in this column, or information in it may be edited, in any published version of this instrument.

3  Authority

  This instrument is made under section 4BA of the Health Insurance Act 1973.

4  Schedules

  Each instrument that is specified in a Schedule to this instrument is amended or repealed as set out in the applicable items in the Schedule concerned, and any other item in a Schedule to this instrument has effect according to its terms.

5  Definitions

Note: A number of expressions used in this instrument are defined in interpretation section of the Health Insurance Act 1973, including the following:

1.       approved pathology practitioner;
2.       pathology service;
3.       pathology services table;
4.       accredited pathology laboratory

 (1) In this instrument:

Act means the Health Insurance Act 1973.

recognised pathologist means a medical practitioner recognised as a specialist in pathology for the purposes of the Act.

 (2) Unless the contrary intention appears, in this Determination a reference to a provision of the Act or regulations made under the Act as applied, adopted or incorporated in relation to specifying a matter is a reference to those provisions as in force from time to time and any other reference to provisions of an Act or regulations is a reference to those provisions as in force from time to time.

6  Services rendered to a patient of a pathologist

For the purposes of section 4BA of the Act, a pathology service is a pathologist-determinable service if:

 (a) the service is described in an item in the pathology services table; and

 (b) the service is rendered, by or on behalf of, an approved pathology practitioner to a patient of that practitioner.

7  Services rendered where a different service was originally requested

For the purposes of section 4BA of the Act, a pathology service is a pathologist-determinable service if:

 (a) the service is rendered, by or on behalf of, an approved pathology practitioner; and

 (b) the approved pathology practitioner considers the service to be necessary, on the basis of information learned from another service:

 (i) that was rendered to the patient by, or on behalf of, that practitioner; and

 (ii) the request for which complied with paragraph 16A(4)(a) or (b) of the Act; and

 (c) the service is an item in the pathology services table that is mentioned in column 1 in the following table and, in relation to which, the pathology service originally requested was an item in the pathology services table that is mentioned in column 2 of the following table for that item of the table:

Note: Items 73319, 73332, 73336, 73337, 73341, 73342, 73344, 73436, 73437, 73438 and 73439 are specified in the Health Insurance (Section 3C Co-Dependent Pathology Services) Determination 2018.

8  Services described in items 69316, 69317, 69319, 69494, 69495, 69496, 69497 and 69498

 For the purposes of section 4BA of the Act, a pathology service that is described in items 69316, 69317, 69319, 69494, 69495, 69496, 69497 or 69498 of the pathology services table is a pathologist-determinable service if it is:

 (a) rendered, by or on behalf of, an approved pathology practitioner who is a recognised pathologist; and

 (b) a service that the approved pathology practitioner determines to be necessary on the basis of:

 (i) information provided by a treating practitioner in relation to a pathology service described in items 69303, 69306, 69312, 69318, 69321 or 69345 of the pathology services table, that was rendered to the patient by, or on behalf of, the approved pathology practitioner pursuant to a request that complied with paragraph 16A(4)(a) or (b) of the Act; or

 (ii) the nature or appearance of the pathology specimen collected for a pathology service described in items 69303, 69306, 69312, 69318, 69321 or 69345 of the pathology services table, that was rendered to the patient by, or on behalf of, the approved pathology practitioner pursuant to a request that complied with paragraph 16A(4)(a) or (b) of the Act; or

 (iii) information learned from a pathology service described in items 69303, 69306, 69312, 69318, 69321 or 69345 of the pathology services table, that was rendered to the patient by, or on behalf of, the approved pathology practitioner pursuant to a request that complied with paragraph 16A(4)(a) or (b) of the Act.

9  A service described in item 72860

 For the purposes of section 4BA of the Act, a pathology service that is described in item 72860 of the Health Insurance (Section 3C Co-Dependent Pathology Services) Determination 2018 is a pathologist-determinable service if it is:

 (a) an initial service that is described in an item in Group P5 (other than item 72860), Group P6 or Group P7 of the pathology services table was rendered in a patient episode for the patient by, or on behalf of, the approved pathology practitioner pursuant to a request that complied with paragraph 16A(4)(a) or (b) of the Act; and

 (b) following the initial service, the treating practitioner determines that a service described in an item in Group P7 (the subsequent Group P7 service) is clinically necessary; and

 (c) following a request from the treating practitioner, an approved pathology practitioner at the accredited pathology laboratory, where the initial service was rendered, determines the accredited pathology laboratory is unable to perform the subsequent P7 service and consequently determines a service described under item 72860 is required to select appropriate tissue samples for referral to a different accredited pathology laboratory for performance of the subsequent P7 service; and

 (d) the subsequent P7 service and a service under item 72860 are rendered in a different accredited pathology laboratory, by or on behalf of, an approved pathology practitioner who is a recognised pathologist.

Schedule 1—Repeals

Health Insurance (Pathologist-determinable Services) Determination 2015

1  The whole of the instrument

Repeal the instrument.