When we must approve care

Last updated: 
18 December 2019

Before we will pay for your services, you may need our approval. We may also need to approve your requests before you can prescribe some medicines and before you can admit clients to some care clinics. This is called requests for prior approval.

What we need to approve

We must approve before you request payment if the:

  • service does not have an item number under the Medicare Benefits Schedule (MBS)
  • fee you charge for the service is more than the fee stated in the DVA Schedule of Fees that is relevant to the service or treatment you are providing
  • service is highlighted in the relevant DVA Schedule of Fees as needing prior approval

You will also need us to approve before you can:

  • prescribe some medicines
  • claim for some dental services
  • admit a client to a hospital or care centre that does not have a contract with us

We must also approve health care services overseas if a client does not want to pay for the service themselves.

If you are unsure whether we need to approve a service or fee, you can call the provider hotline on 1800 550 057. 

You can also call the hotline to check if your client is eligible for treatment. 

You will need to apply for us to approve your request each time it is required. This is the case even if we have approved the same service for the same client in the past.

You should wait until we approve your request before you administer care. If you do not, you may not be able to claim your fee from us.

How you ask us to approve care

For each request you will need to provide:

  • clinical justification for the service
  • any other necessary supporting documents

To request us to agree to pay your fee, complete the relevant form or forms:

Email the form or forms and any required documents to health.approval [at] dva.gov.au or post the form and any documents to:

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

We will write to you and let you know the answer. 

If you need the answer quickly, you must provide a clear clinical reason with your request.

When to expect an answer

We may have an answer for you within:

  • 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

It may take us longer to approve your request if the eligibility for the service is complex, or if the clients eligibility to receive the service is complex. 

To help us approve your request as quickly as possible, you should make sure that you give us all the documents we need.

Requests to approve dentistry services

You will need us to approve your request before you administer any:

  • Schedule B items that are in the Fee Schedule of Dental Services for Dentists and Dental Specialists
  • service that the Fee Schedule of Dental Services for Dental Prosthetists lists as needing prior approval
  • service that either of the fee schedules do not list
  • treatment that includes the use of a general anaesthetic
  • dental implant treatment
  • item or treatment that is above the quantity and/or time limits that the schedules list
  • Schedule C items that are above the Annual Monetary Limit

The clients exempt from the annual monetary limit are people who have Veteran Cards and who have 1 or more of the following:

  • a disability that we accept and that relates to their need for dental services
  • oral malignant neoplasia
  • ex-prisoners of war

See the Dentists, dental specialists and dental prosthetists page to learn more about dental prior approvals.

Requests to admit clients for drug or alcohol care

Some clients can receive services through the Alcohol and Other Drug (AOD) provider panel. Our AOD providers have experience in treating clients who have problems with drugs and alcohol.

These clients are people who have 1 of the following:

  • a Veteran Gold Card
  • a Veteran White Card and you are treating them for a condition that we accept as being related to their service
  • a Veteran White Card and you are treating them for a condition that is a part of our non-liability health care (NLHC) arrangements

You need us to approve your request before you can refer a client to a care centre that:

Your can refer a client to a different centre if 1 of the following applies:

  • there is no space for them at an AOD provider
  • the client has a compelling need to go elsewhere

If the client is in crisis or there is an emergency, you should admit them to a public hospital first.

Requests for health care outside Australia

We must approve requests before:

  • we will pay an overseas health care provider directly for their service
  • the veterans' affairs agencies in New Zealand or Canada pays a provider for us

You can request us to approve when both of the following occurs:

  • if the client has a disability we accept and they cannot pay for treatment of that disability while they are overseas
  • the client does not need urgent treatment

You can use the forms to ask us for prior approval or to see if the client is eligible for the treatment.

We can only approve a request if:

  • it is for a disability or disabilities that we have accepted as being caused by the clients military service
  • it includes a detailed estimate of the cost of the treatment, including a breakdown of fees for doctors, nurses, hospital, rehabilitation and aids
  • it includes an itemised list for the cost per item of any medication
  • you submit 1 at least 4 weeks before the proposed treatment, unless it is for an emergency admission

All requests must be in English, or include a translation of the request into English. We do not pay for the cost of translation.

The Prior Approval Request Form has two parts:

  • Part A - requesting treatment and/or surgery
  • Part B - requesting that we pay the provider directly for treatment

For further information or help to complete this form please call the Health Approvals & Home Care team on 02 6289 1133.

Requests for hospital admissions

You will need us to approve before you admit a client to a hospital that does not have a contract with us.

The hospitals and day procedure centres page has a list of centres that have a contract with us. 

To approve your request you will need to tell us:

  • your provider details
  • the details of the client
  • the client's health condition or conditions that you are treating
  • how much pain or discomfort the client is in
  • the clinical necessity and urgency of the admission
  • the wait times of public or contracted hospitals in your area
  • if you have sought admission to a public or contracted centre

Requests to prescribe medicines

You will need us to approve before you prescribe any of the following:

  • medicines that the Pharmaceutical Benefits Scheme (PBS) and Repatriation Pharmaceutical Benefits Scheme (RPBS) schedules list as needing prior approval
  • greater quantities and/or repeats of medicines than what the PBS and RPBS schedules have listed
  • medicines that are not listed in the PBS and RPBS schedules