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Services requiring prior approval

Prior financial approval is required before providing certain medical and/or allied health services to eligible veterans. The criteria for whether prior approval is required differs for some types of health services. You must submit a request before administering these services to be able to claim payment for the service.

When is prior financial approval required?

  • When the service you are providing has NOT been assigned an item number under the Medicare Schedule of benefits.
  • When the fee you charge for the service you are providing is ABOVE the fee stated in the relevant DVA Schedule of Fees.
  • When the service you are claiming is highlighted with shading in the relevant Schedule of Fees.
  • In the case of dentistry, all items on Schedule B, and items where the treatment provided is above the quantity and/or time limits that apply to the schedule. More about dental prior approvals.

If unsure if prior approval is required please contact the Provider Hotline number: 1800 550 457 — choose Option 3 then Option 1.

Note: Previous approval for a service for an entitled person does not equate to approval for that service for the same person in the future. You must request prior approval for each instance of service, where prior approval is required.

Request prior financial approval

To request prior financial approval you need to carry out the following:

  • complete the relevant form/s
  • ensure you have provided
    • clinical justification for the service
    • any other necessary supporting documentation
  • email the form and any required supporting documents to Health.Approval@dva.gov.au

If you do not have access to email you can post the form and any required supporting documentation to:

Health Approvals & Home Care team
Department of Veterans’ Affairs
GPO Box 9998
Brisbane QLD 4001

What forms and/or documentation do I need to submit?

There are specific forms for certain types of health services. See the following list of forms or visit.

Note: If the service you provide does not have a specific form please complete form D1328 — Treatment Prior Financial Approval Request.

What to expect once you have submitted your request for prior financial approval

DVA will not automatically approve the request for prior financial approval. Currently the DVA will aim to complete a determination on a request for prior approval, within the following standard timeframes:

  • 7 days for Hospital, Surgical, Mental Health, and Diagnostic Imaging requests.
  • 21 Days for Allied Health and General Dental Requests.
  • 60 days for Dental Implant requests.

NOTE: Clear clinical justification must be provided with the request if approval is requested before these timeframes.  

Approval within these timeframes will be dependent upon the following:

  • whether all necessary documentation and information has been supplied
  • the complexity of the eligibility for the service or for the veteran
  • the type of service being requested.

You can assist by ensuring that you follow all guidelines on what information and documentation to submit to request a prior financial approval.

DVA will always advise you in writing of the outcome of the request.

Prior Approval Requests specifically for Alcohol and Other Substance Abuse (AOSA) treatment programs

There are various treatment options available for eligible veterans requiring treatment for alcohol and/or other substance abuse. Information on these options can be found in Factsheet HSV140 — Alcohol and Other Substance Treatment Services.

The majority of these treatment options do not require prior approval where the treatment meets the criteria of having an MBS item number, and is within the DVA fee. Prior approval is also not required where the service is being provided by a hospital or facility that has a contractual arrangement with DVA. Treatments which do not have an MBS item number or are highlighted on the relevant fee schedule require prior approval.

DVA has a panel of community-based providers to assist in treating veterans experiencing alcohol and other substance use disorders. The list of providers on this panel is available from the At Ease online mental health portal. DVA strongly encourages the use of contracted hospitals or providers on this panel in the first instance, as they have undergone rigorous screening.

A list of facilities with Mental Health Private Hospital, contracted to DVA, are available for download from the following:

Where there are no vacancies with approved providers, or there is a compelling clinical need for an individual to access services not provided by the facilities on the panel (or with a contracted hospital or provider) a non-contracted provider may be used. In this instance you will need to seek prior approval using the form D9314 — Prior Approval Request for Treatment of Alcohol and Other Substance Abuse.

Please ensure that you check whether the veteran is eligible for treatment prior to requesting prior approval. You can check this by calling the Provider Hotline on 1800 550 457. Where the veteran does not have an accepted condition relating to alcohol or substance abuse they may still be eligible for treatment under DVA's Non-Liability Health Care (NLHC) arrangements. The veteran will need to contact DVA to register for NLHC.

Where an individual is in crisis or there is an acute emergency, they should be admitted to a public hospital in the first instance.

Prior Approval Requests for DVA clients receiving treatment outside Australia

While overseas, DVA can only fund medical treatment for accepted service related conditions. This does not include conditions accepted under the Non-Liability Health Care or Provisional Access to Medical Treatment arrangements.

Treatment can include:

  • surgery;
  • procedures;
  • physiotherapy, optical, dental or other allied health treatment;
  • pharmaceuticals;
  • aids or appliances.

A request for prior approval is not required for these treatments where a DVA client will pay for the treatment and seek reimbursement from DVA. Prior approval is only required where:

  • DVA is paying the provider directly for the treatment; or
  • The Veterans’ Affairs agencies in New Zealand or Canada will be paying the provider directly on DVA’s behalf
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