Knowledge Base
When Does Medicare Need Referral Details on a Hospital Claim?
The Short Answer
A valid referral is required for all specialist and consultant physician services billed to Medicare. Two pathways exist for documenting it.
Two Pathways
Referral Always Required
- All specialist and physician services
- Initial and subsequent consultations
- Surgical and procedural items
- Mixed claims
- Any service at referred specialist benefit rate
Referral Not Applicable
- Public hospital inpatients
- Pathology and diagnostic imaging
- Non-referred attendance items
The referral covers the whole course of treatment
When a GP refers a patient to a surgeon, that referral authorises the entire episode of care. A new referral is not needed for each individual service within the same course of treatment.
Two Valid Pathways When Admitted
| Pathway | How it works | What goes on the claim | Expires |
|---|---|---|---|
| Standard referral letter | Formal written referral from GP, ED doctor, or another specialist | Referring doctor's name, provider number, and referral date | GP referral: 12 months. Specialist-to-specialist: 3 months |
| In-hospital override | A colleague refers you while the patient is admitted, documented in hospital notes | "Referral within [Hospital Name]" | Expires on discharge |
How the In-Hospital Override Works
1
A colleague refers you
The referral must be written in the hospital record. Even a single signed line in the notes is sufficient.
2
The referring doctor must have consultant status
The referring clinician cannot be an intern or junior RMO. They must hold consultant or senior registrar status.
3
Use the override flag on your claim
On your claim, use the override flag instead of the standard referral fields. In FreshClaim, select "In-hospital referral" from the referral type options.
4
The referral expires on discharge
The in-hospital referral is valid only for the duration of the admission and expires when the patient is discharged.
Rules and Common Mistakes
The override does not reset the 'single course of treatment' clock
An in-hospital override is not a fresh referral. It does not restart the referral period. The original referral's expiry still applies once the patient leaves hospital.
The outpatient follow-up needs its own referral
If you see the patient after discharge in your rooms, the in-hospital override no longer applies. You need a standard GP or specialist referral for outpatient services.
Emergency exception - short window only
In a genuine emergency, a specialist may provide services without a referral. However, this exception covers only a short window of 30 minutes. After that, a referral must be obtained.
Do not backdate referrals
Backdating a referral constitutes a false statement under the Health Insurance Act 1973. If a referral was not in place at the time of service, do not create one after the fact with an earlier date.
How FreshClaim Handles This
FreshClaim default behaviour
FreshClaim defaults every new specialist claim to in-hospital referral. If the patient was referred externally (for example, by their GP), update the referral details before submitting the claim.
Quick Reference Table
| Scenario | What to enter |
|---|---|
| GP referral before admission | Enter referring GP's name, provider number, and referral date |
| ED consultant referral | Enter ED consultant's name and provider number; referral date is the date of the ED consultation |
| Ward colleague referral (in-hospital) | Select "In-hospital referral" and enter the hospital name. No individual provider details required. |
| Locum covering for the referred specialist | Use the original referral details. The referral follows the patient, not the treating doctor. |
| New condition arises during admission | Use in-hospital override for the new condition. The existing referral does not cover unrelated conditions. |
| Post-discharge outpatient review | A new standard referral is required. The in-hospital override expired on discharge. |
| Procedural admission with pre-existing referral | Enter the original referral details. Confirm the referral has not expired (12 months for GP, 3 months for specialist). |
Legislative references: Health Insurance Regulations 2018; MBS Note GN.6.16; Health Insurance Act 1973 s.19(6).
