Provider Atlas

Whether a provider may take part in a given item, by rendering and claiming it or by referring a patient for it, comes down to one thing: the recognition Medicare holds for them. A specialty, a field within it, or a specific credential. RebateRight resolves any provider to their recognitions, then answers, item by item, whether they qualify.

This page maps the recognitions those answers sit on. The map holds three kinds of entry:

Explore the map, then read how the model works below.

Explore the map

Search a recognition by name, or open a branch to see the fields and credentials beneath it. A provider matches an item when a recognition they hold sits at, or below, one the item accepts. One credential works differently. Dual recognition lets a provider refer as a GP, and as a specialist wherever an item accepts a referral from any specialist.

Specialist or consultant physician

A senior doctor can hold either of two Medicare recognitions, and some items care which one.

• Specialist. Earned by fellowship of a specialist medical college. A radiologist, dermatologist, or surgeon is recognised as a specialist.
• Consultant physician. Earned by fellowship of the Royal Australasian College of Physicians or the Royal Australian and New Zealand College of Psychiatrists. A cardiologist, for instance, is a consultant physician, and may hold specialist recognition as well.

The two are not interchangeable. An item may pay a specialist, pay a consultant physician, or accept either, and a claim billed under the wrong one is not paid. The Atlas keeps them on separate branches for exactly that reason.

Fields within a recognition

Under each recognition sit the fields: cardiology, neurology, nephrology, and the rest. Where an item names a field, for example “a specialist or consultant physician in the specialty of cardiology”, RebateRight checks for that field, not the broad class.

Credentials, beyond the specialty

Some items ask for more than a specialty. They require a credential the provider has earned for that specific work: certification in cardiac magnetic resonance imaging, nuclear medicine credentialling, accreditation to perform a transcatheter valve procedure. Holding the specialty is not enough on its own. The provider needs the credential, and RebateRight checks for it directly. These sit in their own branch of the map, marked credential.

The same map, two decisions

A provider’s recognition answers two separate questions, and RebateRight reads both from this one map.

• Who may render and claim. Before a claim is lodged, the recognition decides whether the servicing provider may perform the item and bill it. A claim billed by a provider the item does not accept is rejected; RebateRight catches that up front, so it is right the first time.
• Who may refer. Some items are payable only when the referral comes from a provider with the right recognition, such as a specialist or a consultant physician in a named field. The same map decides whether the referrer qualifies.