Eligible Services

ADF Family Health > Provider Assistance > Eligible Services

If you are not sure if your service is eligible for reimbursement contact 1300 561 454 for clarification.

The Program provides benefits toward eligible services detailed below:

General Practice Service (GP)

As part of the Program, eligible general practice (GP) services are unlimited and are in addition to your family’s benefit allocation (i.e. $800 per registered dependant).

Eligible GP services are those conducted by, or on behalf of, your general practitioner within their general practice setting (e.g. a general practice nurse changing a wound dressing or removing stitches).

To be eligible for claiming, all services must have a Medicare Benefits Schedule (MBS) item number assigned on the paid invoice/receipt. All approved claims for a GP service must be accompanied by a Medicare Statement of Benefits before they are submitted to ADF Family Health for approval.

Specialist Services

Specialist services are provided by Specialists or Consultant physicians within their consulting rooms or a hospital setting. This includes hospital emergency department presentations.

To be eligible for claiming, services must have an MBS item number assigned on the paid invoice/receipt. All approved claims for a specialist service must be accompanied by a Medicare Statement of Benefits before they are submitted to ADF Family Health for approval. These benefits will be deducted from your family’s allocation of funds (i.e. $800 per registered dependant).

Diagnostic and Radiology Services

All diagnostic and radiology services, where there is an MBS item number, are eligible. Services include X-rays, MRIs, pathology, and ultrasounds.

All approved claims will be deducted from your family’s allocation of funds (i.e. $800 per registered dependant).

Allied Services

Allied Health Services provide a broad range of treatments to improve the health and wellbeing of the patients they support. The ADF Family Health Program will pay the gap on the below Allied Health services when they are provided by a certified practitioner.

All approved claims for an allied service will be deducted from your family’s allocations of funds (i.e. $800 per registered dependant).

If you have private health insurance, click here to learn how to reduce your out of pocket expenses further.

Allied Service	Description of Services
Ambulance Subscription	The cost of the subscription to any state or territory-based ambulance service, or an ambulance-only health insurance policy. Please be aware that ambulance services, trips or call-out fees cannot be claimed. To be eligible, the receipt must show the name of a person listed on the ADF Family Health policy.
Audiology	All services conducted by a certified practitioner
Cancer Prevention	You may claim reimbursement for the cost of mole mapping, skin cancer clinic appointments and bowel screening kits. We ask that you submit your claim with an official receipt showing: Service/item you are claiming. Cost of service/item. Date of payment. Provider’s name, address, and ABN number. Customer’s name.
Chiropractic	All services conducted by a certified practitioner
Dental	All items that are listed by the Australian Dental Association (ADA) (items will be paid in line with ADA and independent reasonability rules) Dental items provided at school
Dietician	All services conducted by a certified practitioner
Exercise Physiology	All services conducted by a certified practitioner
Healthy Diet	Dietician led Program Subscriptions Healthy Eating Activity and Lifestyle Program (HEAL). CSIRO Total Wellbeing Diet. Healthy Weight for Life – Self Funded Essentials Program only. Please note the program cannot pay towards any books, food, meal replacements, or additional resources purchased. We ask that you submit your claim with an official receipt showing: Name of program. Cost of program. Date of payment. Provider’s name, address, and ABN number. Customer’s name. Please ensure your claim also includes a referral from a GP, specialist, dietician or physiotherapist stating the medical condition the program subscription is intended to manage. Referrals will remain valid for a maximum of one year from the referral date and will need to be renewed for any claims submitted after that 12-month period.
Immunisations	You may claim for reimbursement of the cost of a vaccine, administering vaccinations not covered under the National Immunisation Program, or vaccinations by a non-GP provider. Please note that vaccinations issued on prescription are covered under the pharmacy benefit. Your claim must include an official doctor’s or pharmacy receipt showing: Patient name Name and cost of vaccination Date the vaccination was administered
Medically Prescribed Appliances (MPA)	Medically Prescribed Appliances (MPA) – claims must be accompanied by a written recommendation/prescription from a certified practitioner.
Occupational Therapy	All services conducted by a certified practitioner
Optical	All prescriptions lenses, frames when accompanied with prescription lenses, contact lenses and lens coatings on prescription lenses.
Osteopathy	All services conducted by a certified practitioner
Other Services	Medicare eye test within a two year period. Emergency department consultation (GP not in a GP setting). Note that services without a Medicare Benefits Schedule (MBS) item number, such as administration, admission and attendance fees are not reimbursable. Midwife conducting obstetrics services when an MBS item is used.
Pharmacy	You may claim reimbursement for the costs of medications that are above the Pharmaceutical Benefits Scheme (PBS) co-contribution amount. As of the 1st January 2024, the PBS amount has been adjusted from $30 to $31.60. All medications must have been provided on a private script from your doctor, and be submitted with an official pharmacy receipt with the below information included: Name and cost of medication Date of supply Strength Quantity Confirmation that the medication was not subsidised by the Australian Government (PBS) Pharmacist’s name, address, and prescription number Customer’s name and address
Physical Activity	You may claim the cost of gym memberships or fitness classes where they form part of a program designed to improve a specific diagnosed health or medical condition. Fitness classes must be facilitated by a provider with a registered ABN, including: Personal Training sessions Yoga classes Zumba classes Pilates classes We ask that you submit your claim with an official receipt showing: Service you are claiming. Cost of service. Date of payment. Provider’s name, address, and ABN number. Customer’s name. Your claim needs to be accompanied by a referral from a General Practitioner, Dietician, Exercise Physiologist or Physiotherapist stating the medical condition the physical activity is intended to manage. Please note the referring health practitioner must not be the one providing the recommended services. Referrals will remain valid for a maximum of one year from the referral date and will need to be renewed for any claims submitted after that 12-month period.
Physiotherapy	All services provided by a certified practitioner. Ante/post – natal classes provided by a registered physiotherapist or midwife
Podiatry and Chiropody	All services conducted by a certified practitioner
Psychology	All services conducted by a certified practitioner, including; Psychometric testing, cognitive behavioural assessment Psychology service with a social worker when an MBS item number is provided Psychology service via video link when an MBS item number is provided
Remedial Massage	All services conducted by a certified practitioner
Speech Therapy	All services conducted by a certified practitioner
Tobacco and Nicotine Addiction	Quit Smoking Courses Alan Carr Quit Smoking Seminar Smokenders Program The cost of an online or in-person course is claimable with a course completion certificate and payment receipt from one of the above foundations. The program does not pay towards any books or additional resources purchased. Nicotine Replacement Nicotine patches Nicotine gum Nicotine lozenges Nicotine inhalers Nicotine mouth spray Your claim must be accompanied with a recognised pharmacy receipt clearly showing: Name and cost of the product Date of purchase