Special Benefit Rules

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Surgical Rules

Surgical Services (SHA-19) pays a case rate per procedure. That single amount covers the procedure and a set number of post-operative nights in hospital - the global period. Almost every surgical billing question reduces to one variable: which post-operative day are you on, and has the global period lapsed?

Surgical interventions require doctor approval

Every surgical intervention requires the attending doctor's approval before the request proceeds. On the SHA Benefits Matrix this is recorded in the doctor's authorisation column, and it reads YES for all 547 surgical interventions (surgical rules 1.1.1, identical on both workbooks).

When needsDoctorAuthorization is true, creating the preauthorisation sends the doctor request automatically. You do not call anything extra. On POST /api/v1/preauths the request goes out to the doctor or doctors named on that preauth, and the preauth waits in PENDING_DOCTOR_APPROVAL until one of them responds. The request reaches the doctor as:

• a two-way SMS they can reply to,
• a request in the Practice360 app, or
• an email.

When the flag is false, no request is sent and the preauthorisation is submitted straight to the payer.

See Surgical Preauthorization for the request itself.

Surgical global periods

The case rate covers a number of nights that depends on the complexity of the procedure. Those nights are the post-operative recovery the case rate is costed to include.

Complexity	Nights covered by the case rate	Beyond that
Minor surgery	1 night	Additional nights at the hospital's gazetted rebate rate
Major surgery	up to 3 nights	Additional nights at the hospital's gazetted rebate rate
Specialized surgery	up to 7 nights	Additional nights at the hospital's gazetted rebate rate

The three global periods are stated identically on both workbooks, so they apply on SHIF and POMSF covers alike (surgical rules 1.3.1.1 to 1.3.1.3).

Complexity is a column on the benefit matrix, carried against each surgical intervention code, so you can see which of the three applies to any procedure by looking it up there. It also comes back per intervention from Intervention Coverage, which is the source to build against - it stays current, and a transcribed copy does not.

No per-diem inside the global period

If more nights are needed once the global period is exhausted, the facility updates the inpatient admission notification to either surgical complication (SHA-07-002 on SHIF, PMF-07-002 on POMSF) or medical admission (rule 1.3.1.4). That switch is what starts the per-diem rebate legitimately.

The SHA Benefits Matrix states the prohibition twice, adding that no per-diem intervention may be added to a surgical episode running inside its global period. The POMSF sheet states the first sentence only. Treat the rule as applying on both.

Three dates must be captured separately

The system must record the admission date, the procedure date and the discharge date as three distinct values (rule 1.3.1.6). They are not interchangeable: the global period runs from the procedure, while the admission may have started earlier.

If the captured procedure and discharge dates contradict the global-period rule - a discharge that cannot be reconciled with the procedure date and the nights the case rate covers - the payer holds the claim for clinical review before paying it (rule 1.3.1.7). This applies on both schemes.

Getting the three dates right therefore matters at capture time: the claim still transmits, and a contradiction between them only surfaces once the payer has looked at it.

What to bill on a given post-operative day

Multiple procedures in one theatre visit

This rule is stated in the SHIF matrix only. Where several surgeries happen within one operating theatre visit on a SHIF cover (SHA surgical rules 1.2):

• the primary procedure is reimbursed at the full gazetted tariff,
• the secondary procedure is reimbursed at 50 percent of its gazetted tariff,
• the treating doctor indicates which procedure is primary.

The POMSF surgical rules sheet carries no equivalent rule. On a POMSF cover, bill the primary procedure and resolve the secondary amount from PMF Tariffs rather than applying the 50 percent reduction yourself.

When a separate claim may be raised

Five situations justify a claim separate from the original surgical claim, even inside the global period.

#	Scenario	Reviewed by the payer
1	A repeat surgical procedure on the same day as the original surgery, requiring a return to the operating theatre	Yes
2	A procedure related to the original surgery requiring an unplanned return to theatre for post-operative complications	Yes - Clavien classification and a practitioner case summary are required
3	A surgical procedure or care, such as critical care, entirely unrelated to the original surgery and not treating its complications	No
4	A staged procedure, defined and planned as part of the primary procedure, performed inside the post-operative global period	No
5	Specialised diagnostic tests such as medical imaging during the surgery	No

The same five scenarios apply on both schemes. They are numbered 1.3.2.1 to 1.3.2.5 in the SHIF matrix and 1.3.3.1 to 1.3.3.5 in the POMSF matrix, renumbered because POMSF inserts an extra rule above them.

Combining surgical care with other packages

The combination rules allow SHA-19 to carry inpatient surgical complications and medical imaging. Critical care and palliative care may be added only after the surgical global period has lapsed - which is the same boundary this page is built around.

The POMSF row additionally permits renal care (SHA-16), which the SHIF row does not list.

Amounts and the catalogue

The surgical catalogue is the largest in the matrix, and the two schemes price the same code differently. No part of it is reproduced here: resolve the amount per intervention from Intervention Coverage and, for a POMSF cover, from PMF Tariffs.

Required documentation

Do not hard-code a document list from this page or from the matrix. Every intervention publishes its own documentation requirements, and they differ per procedure and per scheme.

Read them from Intervention Coverage for the intervention you are billing:

You need	Read this field
Documents required for the claim	applicableDocumentTypes
Documents required for the preauthorisation	requiredPreauthDocumentTypes

See Adding Attachments for those fields in full, the optional counterparts, and how to attach a document once you know its type.

Figures on this page are the non-tariff limits recorded in the SHA Benefits Matrix (05.06.25) and the SHA POMSF Benefits & Tariffs Matrix (10.03.2026). Resolve amounts at claim time from Intervention Coverage.

Related resources

• Special Benefit Rules - the other five rule sets, and the terms used here.
• Surgical Preauthorization - raising the request.
• Preauth Doctor Consent - resending the doctor request if it did not arrive.
• Intervention Coverage - complexity, tariffs, needsDoctorAuthorization and document requirements.
• Inpatient Benefit Rules - the per-diem rules that take over after the global period.
• Critical Care Rules - transitioning to critical care post-surgery.
• Switch Intervention - moving between packages mid-admission.
• Add a claim line - where the primary and secondary amounts are billed.
• Preview Payer Claim - where the payer's review outcome and final status appear.
• Adding Attachments - reading required documents off the intervention.
• Intervention Combination Rules - what SHA-19 may share a visit with.
• PMF Tariffs - resolving POMSF amounts.