Getting prior approval for further treatment

You may need to get prior approval from us before we can fund more treatment for your patient. Find out when you’ll need prior approval and how to get it.

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    When you need prior approval

    If your patient has an injury we cover, you need to get prior approval from us when:

    • the treatment trigger number has, or is about to be reached
    • it’s been more than a year since a health provider last treated the patient
    • you're adding or changing a diagnosis
    • it’s been more than a year since the date of injury.

    Treatment trigger numbers

    Each Read code has a trigger number that shows how many treatments we'll pay for before you need to get prior approval from us. If a read code doesn’t have a trigger number listed, its trigger number will be 6 by default.

    Find the trigger number for a Read code based on the type of provider you are:

    Acupuncture treatment triggers
    Chiropractic treatment triggers
    Osteopathy treatment triggers
    Physiotherapy treatment triggers

    Before requesting prior approval

    There needs to be a clear link between your patient’s ongoing condition and the injury we cover.

    When you ask for prior approval, you need to tell us:

    • the claim number
    • the date of the injury
    • details of the injury
    • what treatment you’ve provided so far.

    If your patient is a new referral you can get this information from our provider helpline.

    Contact us

    Submitting a request for prior approval

    We group requests for prior approval as ‘standard’ or ‘non-standard’. Most are ‘standard’ and follow an easy process.

    Criteria for a standard request

    Your request will be a standard request if it’s:

    • for an injury we’ve already covered
    • made within 12 months of the date of the injury
    • the first request for further treatment from your clinic for the claim
    • for hand splinting and costs don’t exceed $300 (excluding GST)
    • for the original diagnosis
    • for a changed or added diagnosis that’s on the standard Read code list.

    You don’t need to include medical evidence for standard requests.

    Standard Read code list

    Submit a standard request

    There are two ways to make a standard request:

    Phone the provider helpline for an immediate decision
    You’ll need to let your patient know that we’ve approved further treatment.

    Contact us

    Fill in the prior approval form
    Complete the patient treatment and provider details sections of the ACC32 prior approval form:
    Complete the ACC32 application form online

    Criteria for a non-standard request

    If any of the standard criteria aren’t met you’ll need to complete the full prior approval form.

    A request is non-standard when:

    • it’s been more than 12 months since the date of the injury or your patient’s last treatment
    • it’s not the first request for further treatment from your clinic for the claim
    • it’s a request for hand splinting that exceeds $300 (excluding GST)
    • you’ve used the post-surgery codes
    • for changing or adding a diagnosis that isn’t on the standard Read code list.

    Standard Read code list

    Support your request with medical evidence. Attach:

    • patient notes and reports
    • outcome measures
    • patient treatment plan
    • any other relevant medical information.

    We’ll consider each request on a case-by-case basis and tell you if we’ve approved or declined your request.

    Submitting a prior approval form

    You can submit the ACC32 request prior approval form through:

    • the ACC32 online form
    • your HealthLink account
    • email
    • your practice management system.

    Complete the ACC32 application form online


    After you submit a prior approval form

    If you’ve submitted a form, we’ll let you know our decision within three working days.

    There may be a delay if we need a clinical advisor to assess your request, or we need more information. We’ll let you know if this happens.

    When we’ve made our decision we’ll write to you and your patient.

    Contact us

    If you have any questions, contact our provider helpline.

    Phone 0800 222 070 (Monday to Friday, 7am - 7pm)

    Last published: 12 September 2017