Cleft lip and cleft palate scheme
Under the Cleft Lip and Cleft Palate Scheme dental practitioners performing oral and maxillofacial surgery previously needed approval to enable prescribed dental patients to receive Medicare benefits.
However, from 1 November 2004 a practitioner must have medical qualifications and be recognised as a specialist by Medicare before being able to access Medicare benefits for cleft lip and cleft palate services.
The practitioner is now required to apply for specialist recognition via the Specialist Recognition Advisory Committee in the State/Territory in which he/she will be practicing.
An eligible orthodontist is a dental practitioner who either:
- is registered with the Dental Board of Australia in the specialty of orthodontics, or
- is not registered with the Dental Board of Australia in the specialty of orthodontics, and whose qualifications or experience demonstrate to the Australian Society of Orthodontists, prior to 31 March 2013, his or her competence in the field of orthodontics that applies to providing the services, or
- immediately prior to 1 November 2012 was an accredited orthodontist.
Eligible orthodontists can access the Orthodontic services listed in Group C1 of the Cleft Lip and Cleft Palate Services in the MBS.
If you are registered with the Dental Board of Australia in the specialty of orthodontics, you can register your specialty for Cleft purposes by completing the Application for registering a Dental Specialty [PDF, 222Kb].
The patient must be eligible for Medicare and have a cleft lip and cleft palate patient identification card.
A medical or dental practitioner must complete a Certification of cleft condition form and send it to Medicare. The patient, or their parent, is then sent a cleft lip and cleft palate patient identification card.
If your patient hasn't received a new cleft lip and palate patient identification card, or their details have changed, the patient may contact Medicare on 1300 652 492. A security check will be conducted to verify the callers' details. Alternatively details can be provided in writing to:
Cleft Lip and Cleft Palate Scheme
Support and Interpretation Section
PO Box 9822
PERTH WA 6848
The upper age limit for receiving Medicare benefits for cleft lip and cleft palate conditions is now 28 years. This means that all current holders of cleft lip and cleft palate patient identification cards are now eligible for benefits until they reach 28 years.
Before 18 December 2002 the upper age limit was 22 years. For those who turned 22 before 18 December 2002 Medicare benefits are not claimable for the period between when they turned 22 and 18 December 2002.
For example, if the patient turned 22 years of age on 1 September 2002, they cannot claim any Medicare benefits for cleft lip and cleft palate treatments between 1 September and 18 December 2002.
If your patient is over 22 years of age and has not previously been registered in the scheme they will not be eligible for registration or any benefits under the scheme.
The accounts need to have:
- an item number or a description of the service
- the patient’s number that appears on their cleft lip and cleft palate patient identification card, and
- an indication that the service was for treatment associated with their cleft condition.
Permanent dentition treatment items 75039 to 75048 usually form the final stage of treatment for a cleft condition, which is to correct the occlusion (bite).
The Medicare benefit for these treatments is based on a three-year period. The payment system applies a time dependency restriction between items 75039 to 75048:
- a minimum of three months (90 days) between the items
- a maximum of 36 months of the combined total
- Item 75039 (single arch) is the initial treatment item in a course of treatment to permanently correct the occlusion
- Item 75045 (two arch) is the initial treatment item in a course of treatment to permanently correct the occlusion.
- Item 75039 can attract a Medicare benefit twice in a patient’s lifetime
- Item 75045 can only attract a Medicare benefit once
- Items 75042 (single arch) and 75048 (two arch) are the following three months of active treatment to a maximum of 33 months
- Items 75042 and 75048 can attract a Medicare benefit 11 times in a patient’s lifetime
- Item 75042 can attract a Medicare benefit a further 11 times if both jaws are treated in separate treatment episodes
- Item 75800 provides for preventative treatment and prophylaxis of not less than 30 minutes duration each attendance to a maximum of three in a 12 month period.
Extenuating circumstances will be considered and clinical details should be sought from the accredited orthodontist and sent to:
Department of Human Services
Medicare Assessing Section
PO Box 1001
Tuggeranong DC ACT 2901
Regardless of the payment arrangements between the accredited orthodontist and the patient or patient’s parent/carer, the account must indicate a date of service that is three months since the previous service so that it complies with the description of the item, ‘subsequent three months of active treatment’.
For further information about the scheme please call Medicare on 132 150 or 1300 652 492.
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Last updated: 15 July, 2013