Elective Surgery

This policy is inclusive of non-emergency surgical treatment only

June 2013
The WorkSafe Agent can pay the reasonable costs of
elective surgery when required as a result of a work-related
injury or illness when the service is provided by a registered
medical practitioner in accordance with Victorian workers
compensation legislation.
WorkSafe adopts the Medicare Benefits Schedule (MBS)
items, explanations, definitions, rules and conditions for
surgical services provided by suitably qualified medical
practitioners.

surgically implanted prosthetic items as listed on the

current Prostheses List published by the Department of
Health and Ageing (DoHA) and in accordance with the
Surgically Implanted Prostheses Policy.

What information does the Agent require to

consider paying for elective surgery?
Written approval from the Agent is required prior to elective
surgery being performed.

Medical Practitioner Policy

To facilitate a timely decision on the request and to ensure

the most appropriate services are provided to the worker,
the Agent requires a written request from the medical
practitioner that includes:

Reimbursement Rates for Medical Services

name and claim number of the worker

Surgically Implanted Prostheses Policy

name of medical practitioner performing the elective

surgery

This policy must be read in conjunction with the following

documents:

Medicare Benefits Schedule (MBS).

For implantable pain therapy, please also refer to the
Implantable Pain Therapies Policy.

Definition
What is elective surgery?
In this policy, elective surgery is clinically necessary, nonemergency surgical treatment (including surgical
procedures) performed by a registered medical practitioner.

Guidelines
What can the Agent pay for in relation to elective
surgery?
The Agent can pay the reasonable costs of:
surgical services that:
have an item number in the MBS
are clinically justified
are required as a result of a work-related injury or
illness
are requested and performed by a registered medical
practitioner
hospital and theatre fees in accordance with the relevant
and current WorkSafe private hospital fee schedule

brief description of the specific elective surgery requested

clinical indication for the elective surgery and the
relationship between the surgery and the work-related
injury or illness
anticipated prosthesis details, if required. If this is a gappermitted or unlisted prosthesis, written clinical
justification is required - please refer to WorkSafes
Surgically Implanted Prostheses Policy.
The Agent will accept the above information in a letter from
a surgeon to a third party, for example, the referring GP.
This should be provided to the Agent with notification from
the surgeon clearly starting that this is a request for funding.

When will I receive a response from the Agent?

Within 10 working days of receiving the elective surgery
request, the Agent will advise whether:
the request has been approved
the request has been denied
further information is required to make a decision.
Where further information is required, the Agent will advise
whether the elective surgery request has been approved or
denied within 10 working days of receiving the additional
information.

Note: This policy is a guideline issued by WorkSafe Victoria under Victorian workers compensation legislation in respect of
the reasonable costs of services, and services for which approval should be sought from the WorkSafe Agent or self-insurer
(as the case may be) before the services are provided.
WSV1405/03/05.13

Policy for Elective Surgery

What invoicing information does the Agent

require from medical practitioners?

Further Information

It is a WorkSafe requirement that each item billed must be

supported by adequate detail in the hospital operation
report.

Contact the referring Agent, email

info@worksafe.vic.gov.au or refer to:

For further details on the information required when

submitting invoices to the Agent for elective surgery,
please refer to How to Invoice WorkSafe.

Private hospital fee schedules

What fees are payable for elective surgery?

The Agent can pay the reasonable costs of elective
surgery in accordance with the:
Reimbursement Rates for Medical Services
Private hospital fee schedules
Victorian Department of Healths Fees Manual
minimum price of surgically implanted prosthetic items
as listed on the Prostheses List.

In relation to elective surgery what will the Agent

not pay for?
The Agent will not pay for:
services that are not in accordance with the MBS items,
explanations, definitions, rules and conditions for
services provided by medical practitioners unless
otherwise specified by WorkSafe
the provision of hospital operation reports as these
reports form part of the surgical service and are
generated at the time of the surgical procedure
services for a condition that existed before the workrelated injury or illness or that is not a direct result of the
work-related injury or illness
treatment or services where there is no National Health
and Medical Research Council level 1 or 2 evidence that
the treatment or service is safe and effective. Refer to
the Non-established, New or Emerging Treatments and
Services Policy
services that are of no clear benefit to the worker
non-attendance fees where a worker failed to attend
the cost of telephone calls and telephone consultations
between providers and workers, and between other
providers, including hospitals
treatment/services subcontracted to a non-registered
provider
services provided outside of Australia without prior
approval from the Agent
treatment provided to members of the immediate family
of the medical practitioner
invoices that do not meet WorkSafes Invoicing
guidelines for medical practitioners.

Reimbursement Rates for Medical Services

How to Invoice WorkSafe
Medical Practitioner Policy
Implantable Pain Therapy Policy
Surgically Implanted Prostheses Policy
Private Hospital Policy
Non-established, New or Emerging Treatments and
Services Policy
Online Claims Manual (refer to Chapter 10.5)
Medicare Benefits Schedule