The Short Answer
A valid referral is required for all specialist and consultant physician services billed to Medicare, and two pathways exist for documenting it on an inpatient ECLIPSE claim.
When a Referral Is Required
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
Standard referral letter
- How it works
- Formal written referral from a GP, an ED doctor or another specialist.
- What goes on the claim
- The referring doctor’s name, provider number and referral date.
- Expires
- GP referral: 12 months. Specialist to specialist: 3 months.
In-hospital override
- How it works
- A colleague refers you while the patient is admitted, documented in the hospital notes.
- What goes on the claim
- “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 be a consultant or senior registrar
The referring clinician cannot be an intern or junior RMO. They must hold consultant or senior registrar status.
- 3
FreshClaim uses the override flag on your claim
If you don’t manually add any referral details in your submission for an inpatient claim, FreshClaim lodges your claim with an in-hospital override.
- 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: the emergency service only
In a genuine emergency, where the service has to be rendered as quickly as possible, a specialist may provide it without a referral. Services after the emergency need a referral.
Do not backdate referrals
Backdating a referral constitutes a false statement under the Health Insurance Act 1973.
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
| Situation | Referral needed? | On the claim |
|---|---|---|
| Private patient admitted on a GP or specialist referral | Yes: the standard referral | Referring doctor’s name, provider number and referral date |
| Referred from the emergency department | Yes: the standard referral | The ED consultant’s name and provider number. The referral date is the date of the ED consultation. |
| Referred by a consultant or senior registrar during the admission | Yes: the in-hospital override | “Referral within [Hospital Name]”. In FreshClaim, select In-hospital referral. No individual provider details required. |
| A new, unrelated condition arises during the admission | Yes: the in-hospital override for the new condition | The existing referral does not cover unrelated conditions |
| Locum covering the referred specialist | Yes: the original referral | The original referral details. The referral follows the patient, not the treating doctor. |
| Emergency | Not for the emergency service | Where it has to be rendered as quickly as possible. Services after the emergency need a referral. |
| DVA (Veteran Card) patient | Yes: the same periods as Medicare | Referral details as for a standard referral. A GP may write an indefinite referral for a chronic condition. |
| Follow-up in your rooms after discharge | Yes: a new standard referral | The in-hospital override expired on discharge |
| Public patient in a public hospital; pathology and diagnostic imaging; non-referred attendance items | No | — |
| Referral | Valid for |
|---|---|
| GP referral | 12 months from your first service under it, not from the date on the letter, unless the GP writes another period: 3, 6 or 18 months, or indefinite for a chronic condition. |
| Specialist or consultant physician referral | 3 months from your first service under it. For an admitted patient, the admission: it ceases on discharge. |
| In-hospital override | The admission only. It expires on discharge and does not restart the original referral’s period. |
| Indefinite referral | Ongoing for the condition it names. A new or unrelated condition needs a new referral. |
| Emergency exception | The emergency service only, where it has to be rendered as quickly as possible. Later services need a referral. |
| Problem | What to do |
|---|---|
| The referral has expired | Get a new referral before the service. Never backdate one: that is a false statement under the Health Insurance Act 1973. |
| No referral at the time of service, and not an emergency | Bill the attendance as non-referred, at the lower rebate, and obtain a referral before the next service. |
| The referral letter is lost, stolen or destroyed | The claim can still be paid at the referred rate: show the referring doctor’s name and mark the referral as lost on the claim. |
| The in-hospital referrer was an intern or junior RMO | Not a valid in-hospital referral. The referrer must be a consultant or senior registrar; get a valid referral. |
| The referral names a different condition | A referral covers the course of treatment for the condition it was written for. A new or unrelated condition needs a new referral, or the in-hospital override while the patient is admitted. |
Common questions
- Does Medicare require a referral for inpatient specialist claims?
For attendance items, yes. A valid referral is needed for specialist and consultant physician attendances to attract Medicare benefits at the referred rate. Procedural items and pre-anaesthesia consultations (17610 to 17625) do not need one.
- How long is a GP referral valid in Australia?
A GP referral to a specialist is valid for 12 months. A specialist-to-specialist referral is valid for 3 months.
- What is an in-hospital referral override?
An in-hospital referral override is a Medicare pathway where an admitted patient is referred to a specialist by a colleague within the hospital, documented in the hospital record instead of a standard written GP referral. It is valid only for the duration of the admission and expires on discharge.
- Can a specialist bill without a referral in an emergency?
In a genuine emergency, where the service has to be rendered as quickly as possible, an Australian specialist may provide it without a referral. Services after the emergency need a referral.
- Can a Medicare referral be backdated?
No. Backdating a referral constitutes a false statement under the Health Insurance Act 1973.
Legislative references: Health Insurance Regulations 2018; MBS Note GN.6.16; Health Insurance Act 1973 s.19(6).
Referral details, handled at capture
FreshClaim defaults specialist claims to the in-hospital referral pathway and prompts for external referral details when they apply, so claims are complete before they are lodged.