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Now Medibank is onboard with not requiring SEF forms.

Of course until the hospitals stop requesting them, we will still have to issue them from the hospitals point of view.

Cosmetic surgery and the withdrawal of the Specialist Eligibility Form process

31 August 2016

Dear Doctor

I am writing to confirm that, as of August 1 2016, Medibank has withdrawn its requirement for the ‘Specialist Eligibility Form’ (SEF) in respect of certain potentially cosmetic procedures.

In brief, the SEF was introduced in January 2015 to verify the medical basis for procedures that potentially could be cosmetic in nature, to ensure we met our regulatory obligations under the Private Health Insurance Act 2007.

Recently, the MBS descriptors for a number of potentially cosmetic treatments such as lipectomy and apronectomy have been updated by Medicare. These changes align with the criteria Medibank requires to verify the medical basis for these procedures to ensure they are not cosmetic surgery.

Following broad consultation with hospitals and surgeons, Medibank has decided that it will no longer require hospitals to submit a completed SEF with their hospital claims to Medibank. It is important that surgeons continue to work with hospitals to ensure that hospitals are informed by their surgeons of the medical basis for all procedures. This is to ensure that claims are coded by reference to the appropriate medical diagnosis.

For clarity, under Medibank’s agreements with hospitals no benefit is payable by Medibank for any treatment coded in a claim to ICD code Z41.1 or Z42 without a medical diagnosis. Going forward, Medibank will return claims without appropriate diagnostic information from the admitting surgeon, and hospitals will be required to resubmit such claims with a supporting medical diagnosis code.