Alberta Health Billing Explanatory Codes

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Code Explanation
1NOT REGISTERED We have no record of this person registered with this PHN.
01ANOT REGISTERED This person is not registered with the AHCIP. If the patient is a newborn, submit a new claim with a Person Data Segment and the appropriate newborn code. 01B NON RESIDENT We cannot confirm that this patient is an Alberta resident. Please contact the patient to obtain the correct billing information.
01CGOOD FAITH CLAIM Payment was refused as: a) a Good Faith claim was previously paid for this patient; therefore, this patient does not qualify for further Good Faith claim processing orb) Good Faith claims are not payable for visitors to Alberta or for residents covered by the federal government, such as Canadian Forces members or federal penitentiary inmates. Refer to the applicable Resource Guide for information regarding billing alternatives.
2REGISTRATION NUMBER/PERSONAL HEALTH NUMBER CONFLICT The health registration number and the PHN submitted are not for the same person.
3NEWBORN The claim was refused as the AHCIP is unable to contact the parent(s) of this child to confirm registration.
4DONOR'S PERSONAL HEALTH NUMBER USED Submit this claim using the PHN of the donor recipient.
04ACHANGED PERSONAL HEALTH NUMBER This is the correct PHN for this patient. All new claims for this patient should be submitted with this PHN.
5PATIENT PERSONAL HEALTH NUMBER - NOT EFFECTIVE This PHN is not effective for the date(s) of service submitted.
05AINVALID PERSONAL HEALTH NUMBER The PHN is invalid or blank.
05AAOPTED OUT RESIDENT The patient has opted out of the AHCIP. The patient has agreed to assume financial liability for all health services. Please contact your patient regarding payment for your services.
05BUNREGISTERED WORKERS' COMPENSATION BOARD CLAIM The patient is not eligible for AHCIP coverage for the date(s) of service. Submit your claim directly to the WCB.
05BAINVALID/BLANK REGISTRATION NUMBER This claim was refused as the registration number is:(a) blank or(b) invalid.
05BBINVALID/BLANK UNIQUE LIFETIME IDENTIFIER This claim was refused as the ULI is:(a) blank or(b) invalid or(c) not valid for the service recipient.
05CELIGIBILITY EXTENDED HEALTH BENEFITS PROGRAM The patient did not have coverage under the EHB Program for the date of service submitted.
6RETROACTIVE ELIGIBILITY CHANGE Your request to change or reassess this claim was refused. Due to retroactive eligibility change, the patient is not eligible for AHCIP coverage for this date of service.
7NEW RECIPIENT FOR ALTERNATE PAYMENT PLAN CONTRACT Your claim for a new recipient was paid as a FFS benefit.
8NEW RECIPIENT PREVIOUSLY PAID FOR ALTERNATE PAYMENT PLAN CONTRACT Payment was refused as a FFS benefit was previously paid for a new recipient.
9INITIAL ROSTER RELATIONSHIP Payment was refused as an Initial Roster relationship exists for this patient. Therefore, a FFS benefit is not payable under a Temporary Roster relationship.
10INELIGIBLE PRACTITIONER/INCORRECT SUBMISSION We have not received notification from the governing body/licensing association that the practitioner is approved to perform this service.
10ASERVICE PROVIDER RESTRICTIONS Our records indicate that the service provider is:(a) restricted to a specific facility or(b) restricted to performing specific services.
10AAINELIGIBLE PRACTITIONER This claim was refused as you are not entitled to payment for this type of service.
11LOCUM BUSINESS ARRANGEMENT This claim was refused as the BA does not include a BA type of locum.
20INELIGIBLE SERVICES Payment was refused as the services are not eligible for AHCIP coverage. Refer to the general rules in the applicable benefits schedule for examples of ineligible services.
20ATHIRD PARTY SERVICES Payment was refused as these are considered to be third party services. Refer to the general rules in the applicable benefits schedule for examples of third party services.
20ABEXPERIMENTAL/RESEARCH SERVICES Payment was refused as the AHCIP does not pay benefits for services that are experimental and/or in the research stage.
20BARMED FORCES AND FEDERAL PENITENTIARY Armed forces members and federal penitentiary inmates are not eligible for AHCIP coverage.
20CPRACTITIONER BILLING FOR OWN FAMILY Services provided to members of your family or yourself are not a benefit under the AHCIP.
20DDENTAL CARE - ORAL SURGERY This service is not an oral surgical procedure payable by the AHCIP.
20EBENEFITS SCHEDULE This is an incorrect HSC. Please refer to the applicable benefits schedule.
20FEXCLUDED ITEM This service is not payable under the EHB Program.
21WORKERS' COMPENSATION BOARD CLAIM This claim is the responsibility of the WCB.
21ABWORKERS' COMPENSATION BOARD CLAIM SUBMISSIONS Payment was refused as WCB claims are to be submitted directly to the WCB.
22INELIGIBLE PATIENT Our records indicate this claim is the responsibility of another provincial health plan.
23APRIOR APPROVAL Payment was refused as:(a) this service requires prior approval from the patient's provincial health plan and/or(b) prior approval was not received for this date of service.
25EXCLUDED SERVICE - RECIPROCAL PROGRAMS Payment was refused as this service is excluded according to the Reciprocal Agreement. Your claim should be billed directly to the patient or, if applicable, their home provincial health plan.
25AMEDICAL RECIPROCAL - INCORRECT CLAIM Payment was refused as you have submitted a medical reciprocal claim for services provided to an Alberta patient.
28OPTED OUT PRACTITIONER This service was provided by a practitioner who has opted out of the AHCIP and there is no indication that this was an emergency service.
30ADDRESS This claim was refused as the address on the Person Data Segment is invalid, incomplete or blank.
30APROVINCE CODE This claim was refused as the province code on the Person Data Segment is invalid, incomplete or blank.
30AACITY NAME This claim was refused as the city name on the Person Data Segment is invalid, incomplete or blank.
30ABCOUNTRY CODE This claim was refused as the country code on the Person Data Segment is invalid, incomplete or blank.
30ACPOSTAL CODE This claim was refused as the postal code on the Person Data Segment is invalid.
30BDATE OF BIRTH This claim was refused as the date of birth on the Person Data Segment is:(a) blank or(b) invalid or(c) incomplete or(d) after the date of service submitted.
30BAGENDER This claim was refused as the gender on the Person Data Segment is invalid or blank.
30ESURNAME This claim was refused as the surname on the Person Data Segment is invalid or blank.
30EAFIRST NAME This claim was refused as the first name on the Person Data Segment is invalid or blank.
30EBMIDDLE NAME This claim was refused as the middle name on the Person Data Segment is invalid or blank.
30FPERSON TYPE This claim was refused as the person type on the Person Data Segment is invalid or blank.
30GGUARDIAN/PARENT PERSONAL HEALTH NUMBER This claim was refused as the guardian/parent PHN on the Person Data Segment is invalid or blank.
30HGUARDIAN/PARENT HEALTH PLAN NUMBER This claim was refused as the guardian/parent registration number on the Person Data Segment is invalid or blank.
31INCOMPLETE PERSON DATA This claim was refused as the Person Data Segment is:(a) required or(b) incomplete for the person type submitted or(c) required as we have no record of the PHN which was submitted.
31APERSON DATA SEGMENT CONFLICT The out of province registration number and the Person Data Segment do not match the service recipient information in our files. Confirm the patient's out of province health care card registration number, home province/recovery code, and personal data information with the patient or the patient's home provincial health plan. If applicable, submit a new claim with supporting text indicating that the physician has verified the patient’s personal information.
34AACLAIM CURRENT YEAR SEGMENT The current year indicated within the claim number is not numeric or not the current year.
34ABCLAIM SEQUENCE NUMBER The claim sequence number indicated within the claim number is not numeric.
34ACCLAIM CHECK DIGIT The check digit number indicated within the claim number is invalid.
34ADACTION CODE The action code is inconsistent with other information segments within this transaction.
34BEXTRAORDINARY MEDICAL SERVICES ASSESSMENT FUND INDICATOR The extraordinary medical services assessment fund indicator is invalid.
34CCLAIM RECORD TYPE The record type is invalid. To process the claim the record type must be:(a) number 2 in the batch header data field or(b) number 3 in the claim detailed record field or(c) number 4 in the batch trailer data field. Refer to the Electronic Claims Submissions Specifications Handbook.
34DACLAIM TRANSACTION TYPE The transaction type is not CIP1. Refer to the Electronic Claims Submissions Specifications Handbook.
34DBCLAIM SEGMENT TYPE The segment type must be:(a) CIB1 - Claim Regular or(b) CPD1 - Person Data Segment or(c) CST1 - Text Segment or(d) CTX1 - Text Cross Reference Segment or(e) in proper order. Refer to the Electronic Claims Submissions Specifications Handbook.
34DCSEGMENT SEQUENCE NUMBER The segment sequence number is not incremental. Refer to the Electronic Claims Submissions Specifications Handbook.
34DDCST1 SEGMENT REQUIRED At least one CST1 segment must be submitted with an "R" (Reassess Action Code) transaction. Refer to the Electronic Claims Submissions Specifications Handbook.
34DEMAXIMUM CST1 SEGMENT The maximum number of CST1 segments -500 was exceeded.
34DFCIB1 SEGMENT REQUIRED Only provide a "CIB1" Base Claim Segment when submitting a "D" (Delete Action Code) transaction.
34DGCPD1 SEGMENT NOT ALLOWEDA "CPD1" Person Data Segment cannot be provided when submitting an "R"(Reassess Action Code) transaction.
34DHMAXIMUM CPD1 SEGMENTA transaction cannot have more than one "CPD1" Person Data Segment for anyone person data type.
34EACLAIM TEXT SEGMENT The text information you supplied is not in alpha numeric format.
34EBCLAIM SOURCE CODE The claim source code is invalid. Refer to the Electronic Claims Submissions Specifications Handbook.
34ECSUPPORTING TEXT CROSS REFERENCE The Supporting Text Cross Reference segment claim(s) number has failed the claim check algorithm. Refer to the Electronic Claims Submissions Specifications Handbook.
34EDCTX1 AND CST1 SEGMENT The transaction being cross referenced and referred by a "CTX1" Text Cross Reference Segment must have a "CST1" Text Segment.
34FCHART NUMBER The chart number information was not in alpha numeric characters. Only ASCII print characters are valid for this field. Base Claim Segment35 ACTION CODE This transaction was refused as:(a) the Action Code is invalid or(b) Action code "R" (Reassess) is only allowed if text is submitted and the original HSC which was reduced requires reassessment or(c) Action Code "D" (Delete) cannot be processed when the Pay To Code is not "BAPY" or(d) Action Code "C" (Change) cannot be processed on a refused claim.
35AINTERCEPT The intercept code is invalid.
35BRECOVERY CODE The recovery code is invalid or not allowed for this BA.
35CREASSESS REASON CODE The reassess reason code is invalid or blank.
35DCLAIM TYPE The claim type is invalid or blank.
35ECONFIDENTIAL INDICATOR CODE The confidential indicator code is invalid.
35FCLAIM NUMBER The claim number is invalid or blank.
35FASUBMISSION OF A CLAIM NUMBER The claim number submitted was previously used on:(a) refused claim or(b) claim which is being held or(c) a paid service event or claim applied at a zero amount.
35FBUNABLE TO PROCESS UPDATED TRANSACTION The transaction to update a previously submitted claim cannot be processed as:(a) the original add transaction cannot be located or(b) the result of your original claim must be known or(c) the original claim was previously deleted.
35FCUNABLE TO PROCESS ADD TRANSACTION This claim number was previously used and the add "A" transaction cannot be processed. If applicable, submit the original claim number with the appropriate action code of "R" reassess, "C" change or "D" delete.
35GGOOD FAITH INDICATOR The good faith indicator is invalid.
35HSUPPORTING DOCUMENTATION INDICATOR The supporting documentation indicator is invalid.
35JTEXT INDICATOR The text indicator is invalid.
35KPAY TO CODE The pay to code is invalid or cannot be changed.
35KAPAY TO CODE/PAY TO UNIQUE LIFETIME IDENTIFIER CONFLICT There is a conflict between the information shown in the pay to code and the pay to ULI. When the pay to code is "OTHR" (other) the pay to ULI cannot be:(a) the service provider or(b) the BA payee or(c) the patient or(d) the Alberta Health and Wellness registration account holder responsible for the patient.
35LPAY TO UNIQUE LIFETIME IDENTIFIER The pay to ULI is invalid or blank.
35MNEWBORN CODE The newborn code is invalid or not required when the patient's PHN is already provided.
36LOCUM BUSINESS ARRANGEMENT The locum BA number is invalid or not required.
36ALOCUM/BUSINESS ARRANGEMENT NUMBERS The locum BA and the BA fields were not completed properly. Please refer tithe Physician's Resource Guide and submit a new claim.
37BUSINESS ARRANGEMENT The BA number is:(a) invalid or blank or(b) restricted to performing specific services or(c) restricted to performing services at a specific facility or(d) not registered with the submitter of the transaction or(e) restricted to patients from a specific area or(f) does not have a relationship with the practitioner identifier submitted.
37APRACTITIONER IDENTIFIER The PRAC ID is blank, invalid or not effective for the date of service.
37BSKILL CODE The skill code is invalid or blank.
39DATE OF SERVICE The date of service is:(a) invalid or blank or(b) more than one year from date of birth (newborn) or(c) in conflict with the explicit modifier indicated.
39ADATE OF SERVICE CONFLICT The date of service on the claim and the date of service indicated on the supporting documentation do not match.
39BHEALTH SERVICE CODE Payment has been refused as the HSC is:(a) blank or invalid or(b) not listed in the applicable benefits schedule.
39BAGENDER RESTRICTION The HSC and/or diagnosis does not agree with the gender of the patient.
39BBAGE RESTRICTION The patient is not eligible for this service due to age.
39BCHEALTH SERVICE CODE NOT APPROPRIATE FOR DIAGNOSIS The HSC does not agree with the diagnosis.
39BDDATE OF SERVICE/HEALTH SERVICE CODE DATE CONFLICT The HSC is not effective on this date of service.
39BECONCEPTUAL/CORRECTED AGE Payment for the additional benefit was refused as the patient is not eligible due to age. Base Claim Segment (cont'd)39C NUMBER OF CALLS This claim was refused as:(a) the number of calls is invalid or blank or(b) the number of calls is more than the number allowed for this service. If applicable, resubmit the claim with supporting text.
39DLOCATION OF SERVICE The location of service is not appropriate for the HSC.
39DAFACILITY NUMBER The facility number is invalid or blank.
39DBFUNCTIONAL CENTER CODE The functional center:(a) is blank or invalid or(b) is not appropriate for the service submitted or(c) does not exist for the facility submitted.
39DCORIGINATING FACILITY NUMBER The originating facility number is invalid or blank.
39DDORIGINATING LOCATION The originating location code is:(a) invalid or blank or(b) not required when the originating facility number is submitted.
39DEORIGINATING FACILITY NUMBER/LOCATION FOR PATHOLOGY SERVICES The originating facility number or the originating location code is required for pathology services (E HSCs).
39EBDIAGNOSTIC CODE The diagnostic code is blank or invalid.
39ECHEALTH SERVICE CODE AND DIAGNOSTIC CODE CONFLICT The claim was refused as the HSC and the diagnostic code are in conflict.
39FUSE CLAIMED AMOUNT INDICATOR The use claimed amount indicator is invalid.
39FAAMOUNT CLAIMED/USE CLAIMED AMOUNT INDICATOR Your claim was refused as:(a) the amount claimed is blank. Claims for unlisted procedures(HSCs in the 99.09 series) require a claimed amount and a "Y" in the claimed amount indicator field or(b) the amount claimed is blank or invalid and the claimed amount indicator is "Y" or(c) the amount claimed is completed, but the claimed amount indicator is blank or invalid.
39GMODIFIER CODE The modifier code:(a) is required with the HSC submitted or(b) is invalid or(c) can only have one modifier of the same type or(d) cannot have this combination of modifiers or (e) must have a valid two digit numeric suffix when modifier type is SURT or (f) exceeded the maximum number of time units allowed for the modifier type SURT.
39HTELEHEALTH SERVICES This claim was refused as the HSC and the modifier code are in conflict because:(a) the STFO modifier applies only to teledermatology and HSC 03.09Bor(b) the TELES modifier is not attached to this HSC.
41DOCUMENTATION INCOMPLETE/NOT RECEIVED The supporting documentation for this claim was incomplete or not received.
41BTIME/SITES - EXTENDED HEALTH BENEFITS Submit a new claim indicating the number of units, quadrants or sextants.
42HOSPITAL ADMISSION/ORIGINATING ENCOUNTER DATE The hospital admission/originating encounter date is invalid or blank.
43OUT OF PROVINCE HEALTH PLAN NUMBER The out of province health plan number is invalid or blank.
45INVALID REFERRING PRACTITIONER IDENTIFIER The Referring Prac ID is:(a) blank or invalid or(b) not an intraspecialty or(c) from a practitioner without the appropriate discipline or skill.
45AOUT OF PROVINCE REFERRAL INDICATOR The out of province referral indicator is invalid.
45AAREFERRAL PRACTITIONER IDENTIFIER INVALID/INABLE TO RESOLVE Your claim was refused as the referral PRAC ID is invalid. Contact the referring practitioner for the correct PRAC ID.
45BENCOUNTER NUMBER The Encounter number is invalid.
47SERVICE RECIPIENT PERSONAL HEALTH NUMBER This claim was refused as the service recipient PHN cannot be changed. Delete
48PRACTITIONER IDENTIFIER This claim was refused as the PRAC ID cannot be changed. Delete the original claim and submit a new claim with the correct PRAC ID.
49BUSINESS ARRANGEMENT/LOCUM BUSINESS ARRANGEMENT NUMBER This claim was refused as the BA and/or locum BA number cannot be changed. Delete the original claim and submit a new claim with the correct BA or Locum BA number.
50TWO PHYSICIANS - UNRELATED ABDOMINAL SURGICAL PROCEDURES Payment was reduced to 75% of the benefit as the full benefit for the major procedure was paid to the physician most responsible for the patient’s care.
50APROCEDURES INCLUDED IN THE MAJOR PROCEDURAL BENEFIT Payment was refused as this service is included in the benefit paid for the major procedure.
50AADIAGNOSTIC PROCEDURES RELATING TO SURGERY Payment was refused as the diagnostic procedure is included in the benefit paid for the surgical procedure when performed under the same anesthetic.
50ABSECOND OR SUBSEQUENT PROCEDURE Payment for the procedure was reduced to 50% as this service was performed as a second or subsequent procedure through the same incision.
50BREPEAT CLOSED REDUCTION - SAME PRACTITIONER Payment was refused as a repeat closed reduction performed by the same practitioner is not payable.
50BAREPEAT CLOSED REDUCTION - DIFFERENT PRACTITIONER Payment was reduced to 50% as a different practitioner performed a repeat closed reduction for the same fracture or dislocation.
50BBCLOSED - OPEN REDUCTION - DIFFERENT PRACTITIONER Payment was reduced to 50% as a different practitioner performed an open reduction for the same fracture.
50BCCLOSED - OPEN REDUCTION - SAME PRACTITIONER Payment was refused as a closed reduction is not payable when the same practitioner performs an open reduction for the same fracture under the same anesthetic.
51PRE AND/OR POST-OPERATIVE CARE - TWO PRACTITIONERS Payment was reduced or refused as another Practitioner was paid for pre-and/or post-operative care.
51AUNILATERAL - BILATERAL PROCEDURES Payment was reduced as the benefit does not increase when a bilateral procedure is performed.
51GSURGICAL ASSISTS Payment was refused as:(a) a surgical assist benefit is not payable for the procedure submitted or(b) a surgical procedure was not claimed for this date of service or(c) documentation was not submitted to support a claim involving unusual circumstances.
52ALACERATIONS Payment was made according to the explanation following HSC 98.22B.
52BSAME PHYSICIAN - TWO FUNCTIONS Payment was refused as only one benefit can be paid when both surgical and anesthetic services are performed by the same physician.
54INCLUDED SERVICES Payment was refused as the service(s) is included in the benefit paid for the delivery.
54APOSTNATAL MAXIMUM Payment was refused as only one routine postnatal visit per physician is payable.
54BPRENATAL CARE Payment was refused as:(a) only one HSC 03.04B may be claimed per pregnancy per physician or(b) 03.04B may not be claimed within 91 days of a major visit HSC or(c) 03.03B may only be claimed for the prenatal visits and not for dates of service following a delivery.
56PROCEDURE - VISIT Payment was refused as:(a) only the greater of a minor procedure or office visit is payable when the services and diagnosis are related or(b) only the greater of a consultation and minor procedure are payable on the same date of service or(c) only the greater of a procedure and hospital visit are payable on the same date of service.
56AMULTIPLE MINOR SURGICAL PROCEDURES Payment was reduced to 75% as only the greater benefit is payable in full when multiple minor surgical procedures are performed.
56BVARICOSE VEINS INJECTIONS Payment was refused as the maximum for the benefit year (July 1 to June 30)was paid.
56CTRAY SERVICES Payment was reduced or refused according to the applicable benefits schedule.
56DFIBREGLASS CAST(a) Payment was reduced to the equivalent rate of HSC 07.53B or07.53D as the service was performed in a nursing home, general or auxiliary hospital, AACC, UCC or a facility which has a contract with an RHA or(b) Payment was reduced by a rate equivalent to 07.53B or 7
53Das the benefit for the application of a cast is included in the fracture reduction HSC or(c) Payment was reduced by a rate equivalent to a major tray service benefit which was paid for 07.53B or 7
53Das cast supplies are included in the benefits for 07.53H and 07.53J.
58TWO PROCEDURES - TWO SURGEONS Payment was reduced as the greater anesthetic benefit is paid at 100%and the lesser at 75% when two procedures are performed consecutively by two surgeons under the same anesthetic.
58AINCLUSIVE ANESTHETIC BENEFIT Payment was refused as pre- and/or post-anesthetic visits are included in the anesthetic benefit.
58BLOCAL ANESTHETIC Payment was refused as only the greater benefit is payable when both the local anesthetic and the procedure are claimed by the same practitioner.
58BASIMULTANEOUS SURGERY Payment was refused as only the greater anesthetic benefit is payable when two practitioners operate simultaneously.
58CMULTIPLE BENIGN SKIN LESIONS Payment was reduced or refused as only a single anesthetic benefit is payable when surgical treatment of multiple benign skin lesions is performed under anesthetic of less than 35 minutes duration.
58ERELATED ANESTHETIC CODE Payment was made according to the information submitted on the surgeon’s claim.
58FADDITIONAL AGE BENEFIT Payment was reduced as only one additional anesthetic benefit per case is payable regardless of the number of anesthetic services provided.
60INITIAL VISIT - MAJOR Payment was refused as an initial visit provided by the same practitioner may not be claimed more than once every 180 days.
60ACONSULTATION - INCLUSIVE BENEFIT Payment was refused as a consultation benefit is included in the procedural benefit.
60AACONSULTATION Payment was reduced to the rate payable for a non-referred visit HSC as:(a) the service does not meet the requirements of a consultation or(b) the referral was not from a physician, midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner, or(c) the referral was from a family member.
60BDENTAL CONSULTATION Payment was refused as a dental consultation is only payable when it is requested by the patient's physician, dental surgeon, or oral and maxillofacial surgeon and it concerns a procedure payable under the Schedule of Oral and Maxillofacial Surgery Benefits.
60CHOSPITAL ADMISSION Payment was refused as an admission is not payable when the patient was seen by the same practitioner on the same day for the same or related diagnosis.
60EEMERGENCY DEPARTMENT/ADVANCED AMBULATORY CARE CENTRE/URGENT CARE CENTREVISITS Payment was refused as:(a) another physician has claimed for the same service. Submit a new claim with a DSCH modifier in accordance with General Rule 5.1.4 or(b) HSCs 03.05F, 03.05FA and 03.05FB cannot be claimed by the same physician who provided the initial assessment prior to determining the disposition status of the patient.
60EACRITICAL CARE - EMERGENCY DEPARTMENT/ADVANCED AMBULATORY CARECENTRE/URGENT CARE CENTRE VISIT Payment was refused as the information/diagnostic code provided does not support payment under this HSC. Submit a new claim with the appropriate emergency department/AACC/UCC visit HSC.
60EBSERVICES UNSCHEDULED Payment was refused as the maximum benefit for unscheduled services was reached.
60ECSPECIAL CALLBACKS TO ADVANCED AMBULATORY CARE CENTRE/URGENT CARE CENTREHOSPITAL EMERGENCY OUT PATIENT DEPARTMENT Payment was refused according to GR 5.2 in the Schedule of Medical Benefits or GR 17 in the Schedule of Oral and Maxillofacial and Surgery Benefits.
60EDMAXIMUMS FOR SPECIAL CALLBACKS AND SURCHARGES Your claim was refused or reduced in accordance with the general rules in the applicable benefits schedule.
61DRESSING CHANGES - BURNS Your claim for HSC 07.57A and/or 07.57B has been changed to a visit HSC as the service is not for a burn. The corresponding tray service benefit has been deducted where applicable.
61AGENERALIZED DIAGNOSTIC CODES Payment was refused as this service is included in the benefit paid for the related surgical procedure.
61BREMOVAL OF SUTURES Payment was refused as the benefit for removal of sutures is included in the procedural benefit.
61CNURSING HOME AND SENIOR CITIZENS HOME Payment was refused as the service was not provided in a "home" location.
61CAAUXILIARY HOSPITAL VISITS Payment was reduced to a lesser benefit as the service provided was a routine visit for custodial care.
61CBAUXILIARY HOSPITAL/NURSING HOME VISIT/MANAGEMENT OF DIALYSIS PATIENTS Payment was refused as a visit was paid for a prior date of service during the same calendar week.
61ECONCURRENT CARE Payment was reduced or refused as services for concurrent care require supporting information.
61EACONTINUING CARE Payment was reduced or refused in accordance with the applicable benefits schedule.
61FCONFLICTING HOSPITAL DATES Payment was reduced or refused as a benefit for some or all of the hospital dates of service was previously paid.
61GPOST-PARTUM OFFICE VISITS Payment was refused as this service is not payable when provided to a healthy newborn during the post-partum period.
61HINCLUSIVE - SURGICAL BENEFIT - PRE/POST-OPERATIVE CARE Payment was refused as pre- and/or post-operative care is included in the procedural benefit.
62PROFESSIONAL INTERVIEW/CASE CONFERENCE Payment was refused as HSC 03.05YM may only be claimed when 03.05Y has been previously submitted and paid.
63CLAIM IN PROCESS Your claim is being held as:(a) it requires manual assessment or(b) the supporting information must be reviewed. DO NOT SUBMIT A NEW CLAIM, as notification of payment or refusal will appear on a future Statement of Assessment.
63ASCHEDULE OF BENEFITS Payment for your claim was reduced or refused in accordance with the applicable benefits schedule. To view the benefits schedules, go to the Alberta Health and Wellness website at health.alberta.ca.
63AAUNSCHEDULED SERVICES & DESIGNATED HOLIDAYS Payment was reduced or refused according to the applicable benefits schedule.
63ACPandemic Telephone Advice This claim was refused in accordance with the notes following HSC 03.01AD.63B MAXIMUM NUMBER OF CALLS Payment was reduced as the maximum number of calls for the HSC was reached.
63CINCLUSIVE HEALTH SERVICE CODE Payment was refused as there is an inclusive HSC for these services.
64SUPPORTING INFORMATION Payment was refused as text information, an operative or pathology report, or an invoice is required to support assessment of the claim.
64AAUNANSWERED CORRESPONDENCE/TELEPHONE RESPONSE Payment was refused as our requests for additional information were not answered.
64ABRELATIONSHIP Payment was refused as the relationship of the relative being interviewed was not provided.
64CINFORMATION PROVIDED The information provided has been reviewed and payment was:(a) reduced or refused or(b) unchanged or(c) altered. Future claims of this nature should be submitted under the applicable HSC. HSCs under the 99.09 series (Unlisted Procedures) are to be claimed only for unlisted procedures.
64DANESTHETIC AND SURGERY DISCREPANCY Payment was refused as there is a discrepancy between the HSCs submitted on the anesthetic and the surgery claims.
64EDATE CONFLICT Payment was refused as the date of service does not agree with the anesthetist's, surgical assistant's or surgeon's claim, as applicable.
65NON-INVASIVE DIAGNOSTIC PROCEDURES IN HOSPITAL/ADVANCED AMBULATORY CARECENTRE/URGENT CARE CENTRE Benefits for non-invasive diagnostic procedures including laboratory and pathology and diagnostic radiology services performed for a hospital inpatient, registered outpatient, AACC or UCC patient are not payable under the AHCIP. Payment for these services is the responsibility of the hospital/RHA. This applies to both the technical and professional components.
65ABLOOD SPECIMEN This claim was refused as payment cannot be made:(a) for both obtaining a blood specimen and a laboratory test requiring blood or(b) for services performed by non-laboratory facilities.
65AAMISCELLANEOUS LABORATORY PROCEDURES Payment was refused as:(a) claims submitted for HSC E1 and/or combination of E2, E3, E4, E5 and E7for the same date of service are not payable in excess of the benefit for E1 or(b) the greater benefit is paid when claims are submitted for E1 and E41 orE400 for the same date of service or(c) the greater benefit is paid when claims are submitted for E234 and E235for the same date of service or(d) a maximum of either one E553 and one E554 or two E553s or two E554s are paid within a 14 day period.
65DALLERGY INVESTIGATIONS Payment was reduced or refused as the maximum benefit for the 365 day period was reached.
65EDETENTION TIME Payment was refused as supporting information must provide a breakdown of the procedures performed during the time of continuous attendance spent with the patient and the time of attendance during the ambulance trip, if applicable.
66DETENTION TIME Payment was reduced or refused as:(a) when a consultation or visit is claimed in association with HSC 03.05Aor 13.99J during the same encounter, the consultation is considered to occupy the first 30 minutes of the time spent with the patient or(b) the greater benefit is paid when 03.05A or 13.99J are claimed for the same patient encounter.
66AVENTILATORY SUPPORT Payment was reduced or refused as:(a) ventilator support is payable only once every 24 hour period regardless of the number of physicians providing care or(b) ventilator support is not payable for the same date of service to the same physician who was paid for either an anesthetic or surgical procedure or(c) ventilator support is not payable unless provided in approved level2 and 3 intensive care and neonatal intensive care units.
67MULTIPLE CHARGES/SAME ENCOUNTER Payment was refused as claims for multiple services provided in the same encounter require supporting information.
67APREVIOUS PAYMENT Payment for this service was refused as:(a) the claim was previously paid or(b) the claim was applied at "0" on a previous Statement of Assessment or(c) the claim was previously paid under a different HSC for the same service under another benefits schedule. NOTE: Requests for a reassessment of applied at "0" claims must be submitted with the original claim number and the appropriate action code of "C" (Change), "D" (Delete) or "R" (Reassess). Hospital reciprocal claims are an exception and must be resubmitted as described in the Alberta Health and Wellness Hospital Reciprocal Claim Submission Guide.
67AAPAYMENT TO ACCOUNT HOLDER/PATIENT Payment was refused as the benefit for this service was paid to the accountholder/patient.
67ABPREVIOUS PAYMENT - DIFFERENT HEALTH SERVICE CODE Payment was refused as a benefit was paid under a different HSC.
67ACPREVIOUS PAYMENT Payment was refused as this benefit was paid to another practitioner.
67ADDUPLICATE - DIFFERENT SERVICE DATE Payment was refused as this claim appears to be a duplicate of a previously paid benefit, although the dates of service do not agree. If this is not a duplicate, submit a new claim with supporting information.
67AEPREVIOUS PAYMENT WARD RATE/ICU RATE Payment for this service was refused as: a) the ward rate was previously paid orb) the ICU rate was previously paid.
67BLOCATION OF SERVICE CONFLICT Payment was refused as claims were paid for services that the patient received on this date at a different location/hospital.
Verify the dates and resubmit applicable claims with additional details.
69ALTERNATE PAYMENT PLAN ADDITIONAL FEE FOR SERVICE PAYMENTS An additional FFS payment was paid due to additional supporting documentation for special circumstances.
70PRE/POST-OPERATIVE CARE This claim was assessed in accordance with the general rules in the applicable benefits schedule.
70ATWO DENTAL PROCEDURES Payment was reduced to 75% of the listed benefit as the major surgical procedure was paid at the full rate.
70DINELIGIBLE DENTAL SERVICES Payment was refused as:(a) tissue conditioning is only payable in conjunction with a denture or reline within five years and no reline or denture was claimed for this period or(b) tissue conditioning is not payable within three months of a partial or complete denture insertion as it is included in the denture insertion benefit or(c) only two tissue conditioning benefits are payable for a denture or reline within five years. The maximum benefit has been reached.
70ETOOTH IDENTIFICATION Payment was refused as:(a) identification of tooth numbers and/or surfaces is required or(b) the tooth surface field for this procedure must be blank or(c) the tooth surface(s) indicated is not valid for the tooth code or(d) the tooth number indicated is not valid for this procedure.
70EADENTAL EXTRACTION Payment was refused as our records show this tooth was previously extracted.
70EBTOOTH SURFACE/TOOTH CODE Payment was refused as the tooth surface or tooth code is invalid.
70FDENTURES/REBASE/RESET Payment was refused as a benefit was paid for a partial or complete denture within the last five years.
70GRELINE OR REBASE Payment was refused as benefits were paid for a reline in the past two years.
70JINCLUSION WITHIN THE COMPOSITE BENEFIT Payment was refused as the service is included in the benefit for the major procedure.
70KINELIGIBLE DENTAL MECHANICS SERVICES Payment was reduced or refused as:(a) only one oral examination per day is payable when a corresponding new denture or reline benefit is provided on or after January 1, 2001 and paid by the EHB program or(b) only one oral examination is payable for each new denture or reline service provided or(c) an oral examination occurred within 90 days of the denture/reline service. The examination is included in the benefit for the denture/reline or(d) an oral examination is not payable if performed more than 365 days after a denture or reline benefit was provided.
70LDENTAL PROCEDURES Payment was refused as when multiple services are claimed for the same date of service, the following applies:(a) only the greater benefit of a minor procedure, consultation or any visit is payable when the services and diagnosis are related or(b) only the greater benefit of a minor (M or M+) procedure or a hospital visit is payable, regardless of the diagnosis or(c) only the greater benefit of a minor (M+) procedure or a visit is payable when performed in a location other than an oral and maxillofacial surgeon's or dentist's office or surgical suite, regardless of the diagnosis or(d) an office visit benefit is not payable with a minor (M+) procedure and a consultation, regardless of whether the services are performed at different encounters.
73ADDITIONAL COMPENSATION CLAIMS Payment was refused as claims from non-residents, subscribers and allied health professionals with the exception of podiatric surgeons, do not qualify for additional compensation benefits.
73AADDITIONAL COMPENSATION COMMITTEE This claim was paid, reduced or refused as recommended by the Additional Compensation Committee.
73BAINCORRECT ADDITIONAL COMPENSATION CLAIM SUBMISSION Payment was refused as the claim for additional compensation was submitted incorrectly.
73BBNO PAYMENT BY AHCIP Payment of the additional compensation portion of the claim was refused as there is no record of an AHCIP payment for this service.
73BCREQUEST FOR ADDITIONAL COMPENSATION Payment was refused as supporting documentation is required for the additional compensation portion of the claim.
73BDNON-INSURED SERVICE Payment was refused as this service is not insured by the AHCIP.
73BECHANGE OF PAYMENT RESPONSIBILITY This additional compensation claim was paid as an AHCIP benefit.
80RESIDENCY/GOOD FAITH Payment was refused as Good Faith claims must be submitted within 30 days of the date of service.
80BEYE EXAMINATIONS Payment was refused as this is the second claim for this type of eye examination for this patient within the benefit period (July 1 to June 30).
80BAOPTOMETRIC SERVICES Payment was refused as either a complete vision examination, a partial vision examination or a single diagnostic procedure was paid for the same date of service; or the maximum benefit allowed was reached.
80BDFOLLOW-UP VISIT (HSC B901) TEST REQUIRED Payment for B901 was refused as the patient received the corresponding B900within 90 days and no explanatory text was provided. Subject to the Optometric Benefits Regulation section 12(2), a claim for a B901 performed within 90 days of a B900, where the diagnostic code falls within Optometric Benefits Regulation section 12(1), must be accompanied by explanatory text unless the resident's eye care is subject to a co-management arrangement.
80BEMAXIMUM BENEFIT REACHED Payment was refused as the patient has received the maximum benefit payable for this condition/episode subject to the rules in the Optometric Benefits Regulation sections 12(1), 12(3) and 12(4).
80BFPREVIOUS PAYMENT, SAME DATE OF SERVICE Payment was refused as:(a) a benefit was paid under a different HSC or(b) a benefit was paid to another practitioner or(c) a benefit was previously paid.
80BHCOMPUTER ASSISTED VISUAL FIELDS (B905) - TEXT REQUIRED Payment was refused as explanatory text was not provided. Subject to the Optometric Benefits Regulation section 13(2), a claim for B905 must be accompanied by explanatory text unless the diagnostic code submitted is Glaucoma (365.0-365.8), Retina Detachments and Defects (361.0-361.3, 361.8)or Disorders of the Optic Nerve and Visual Pathways (377.0-377.7).
80CPODIATRIC/DENTAL LIMITS This claim has been reduced or refused as:(a) the yearly limit for podiatric benefits has been reached; however payment may be reviewed at a later date if changes to other related claims for this patient are received or(b) the calendar year limit for the following dental service(s) has been reached: -a benefit for only two examinations of any type may be paid in a calendar year or -a benefit for only two films may be paid in a calendar year or -a benefit for panoramic x-rays may be paid once every five calendar years or -a benefit for no more than two units of time (30 minutes) for subgingival scaling/root planing may be paid in a calendar year.
80DEYEGLASSES/LENSES/FRAME Payment has been reduced or refused as this patient has received:(a) eyeglasses within the last three years or(b) lenses/lens within the last three years.
80FTWELVE MONTH LIMIT Payment has been reduced or refused as the patient has received this benefit within twelve months.
80GOUTDATED CLAIMS Payment was refused as the time limit for submission has expired.
80HCONTRACT LIMITS Payment was reduced or refused as the contract limit was reached.
80JPRACTITIONER/BUSINESS ARRANGEMENT LIMITS Payment was reduced or refused as the limit was reached for the service provider or the BA.
80KRECIPIENT LIMIT HAS BEEN REACHED FOR ALTERNATE PAYMENT PLAN CONTRACT Payment was refused or reduced as the recipient has reached capitation rate.
80LALTERNATE PAYMENT PLAN FEE FOR SERVICE Payment was reduced as the capitation maximum was paid for the month of service.
90PAYMENT REDUCTION This is an adjustment of a previously assessed item.
90APREVIOUS CORRESPONDENCE - MUTUAL INFORMATION This claim has been assessed in accordance with correspondence or telephone call.
90DADJUSTMENT, RECIPIENT NO LONGER ELIGIBLE FOR COVERAGE This is an adjustment to update your records only. Payment has not been deducted from your account. NOTE: The patient is not eligible for AHCIP coverage for the date of service and will be billed by the AHCIP.
90EADJUSTMENT, RECIPIENT DECEASED This is an adjustment to a previously assessed claim. Our records indicate that the patient's date of death is prior to the date of service. Please check your records to confirm the date of service. If the wrong date of service was used, submit a change transaction with the correct date of service.
95NEWBORN Payment was refused as the diagnosis submitted does not agree with the ward rate claimed.
95AINPATIENT/OUTPATIENT SERVICES Payment was refused as an inpatient and an outpatient service provided at the same hospital on the same day to an individual patient is not payable.
95BDAY OF DISCHARGE Payment has been reduced as the standard ward rate is not payable for the day of discharge.
95CHIGH COST PROCEDURE/ZERO WARD RATE Payment was refused as when a high cost procedure and an inpatient standard ward rate are being claimed, two separate claims must be submitted:(a) one claim showing the admission and discharge date and an inpatient standard ward rate, with the claimed amount of zero, and(b) the other claim for the high cost procedure.
95DMULTIPLE TRANSPLANTS SAME HOSPITAL STAY Payment was refused as multiple same organ transplants within the same hospital stay are not payable.
95EREDUCED BENEFITS Payment has been reduced as the number of days between the admission and discharge dates do not agree with the claimed amount.
95FOUTPATIENT SERVICES Payment was refused as an outpatient hospital service has been previously paid for this patient for this date of service.
95GMAXIMUM NUMBER OF SERVICES Payment was refused as the maximum number of services was paid.
95KCLAIM IN PROCESS Hold for documentation.
95LOUT OF PROVINCE REGISTRATION EXPIRY DATE Payment was refused as the out of province registration expiry date must be blank if the out of province registration number is blank.
95MUNABLE TO PROCESS UPDATED TRANSACTION The transaction to update a previously submitted claim cannot be processed as:(a) the original add transaction cannot be located or(b) the result of your original claim is unknown, or(c) the original claim was previously deleted. Please review your records and resubmit, if applicable.
95TINVALID ICD10CA DIAGNOSTIC CODE Payment was refused as the diagnostic code is invalid. Only the International Statistical Classification of Diseases and Related Health Problems, 10th Canadian Revision, diagnostic codes (ICD10CA) are acceptable for hospital reciprocal inpatient billing. HOSPITAL RECIPROCALADJUSTMENTS REQUESTED BY HOME PROVINCE96A MOTHER/NEWBORN REGISTRATION NUMBER This is an adjustment of a previously processed claim. Payment was deducted as the mother's out of province registration number may not be used for a baby over the age of three months. Please obtain the baby's correct out of province number and resubmit the claim.
96BDECLARATION FORM INCOMPLETE/INCORRECT This is an adjustment of a previously processed claim. Payment was deducted as the Declaration Form requested by the patient's home province was:(a) not provided or(b) incomplete or(c) not signed by the patient or parent/guardian.
96COUT OF PROVINCE PATIENT INFORMATION/CLAIM INFORMATION DISCREPANCY This is an adjustment of a previously processed claim. Payment was deducted because there is a discrepancy between:(a) the home province's patient registration information and the patient information submitted or(b) the expiry date on the patient's health card and the expiry date submitted.
96DOUT OF PROVINCE PATIENT'S COVERAGE NOT EFFECTIVE This is an adjustment of a previously processed claim. Payment was deducted as the patient's home province has verified that the patient's health card was not valid on:(a) the date of service or(b) the admission date or(c) the discharge date.
96EINCORRECT CLAIM - ALBERTA RESPONSIBILITY Our records indicate that the patient was an Alberta resident on the date of service; therefore, this claim has been:(a) refused or(b) adjusted from your previous payment.
96FWORKERS' COMPENSATION BOARD RESPONSIBILITY This is an adjustment of a previously processed claim. Payment was deducted as we have received information advising this service is the responsibility of the WCB. This claim should be submitted directly to the WCB.
96GINCORRECT SERVICE/DATE OF SERVICE/RATE CLAIMED This is an adjustment of a previously processed claim. Payment was deducted at the request of the patient's home province as an incorrect:(a) service or(b) date of service or(c) rate was claimed. Please submit a new claim using the correct information, if applicable.
96HSECOND OUTPATIENT VISIT This is an adjustment of a previously processed claim. Payment was deducted as multiple outpatient visits on the same day for the same patient are not payable. Note: Charges for additional outpatient visits may not be billed directly to the patient or home province. HOSPITAL RECIPROCALADJUSTMENTS REQUESTED BY ALBERTA RHA/HOSPITAL97A INCORRECT SERVICE/DATE OF SERVICE/RATE CLAIMED This is an adjustment of a previously processed claim. Payment was deducted at the request of the Alberta RHA/hospital as an incorrect:(a) service or(b) date of service or(c) rate was claimed. Please submit a new claim using the correct information, if applicable.
98CAPITATION PAID Payment was refused as capitation (payment in lieu of FFS benefits) was paid for this patient for this date of service.
98AINVALID HEALTH SERVICE CODE Payment was refused as this HSC may not be claimed by the BA indicated.
98AAFEE FOR SERVICE/ALTERNATE PAYMENT PLAN REASSESSED CLAIMS Thank you for your payment. Your FFS claim transactions have been reassessed and applied as APP billing. ALTERNATE PAYMENT PROGRAM (APP) RELATEDREGISTRATION98B NON PATIENT-SPECIFIC UNIQUE LIFETIME IDENTIFIER - OTHER INTERVENTIONS This transaction was refused as the non patient-specific ULI must be used for services defined as other interventions.
98CLOCUM BUSINESS ARRANGEMENT - FEE FOR SERVICE This transaction was refused as a practitioner with a locum BA may not be paid FFS under an APP practice.
98DOTHER INTERVENTIONS - NON-ENROLLED PATIENTS This transaction was refused as services defined as other interventions may not be submitted for non-enrolled patients.
98DAOTHER INTERVENTIONS NOT ELIGIBLE UNDER GOOD FAITH This transaction was refused as services defined as other interventions may not be claimed under the Good Faith program.
98DBINELIGIBLE OTHER INTERVENTIONS This transaction was refused as this other intervention service may not be claimed under this APP program.
98DCDATE OF SERVICE/ALTERNATE PAYMENT PLAN EFFECTIVE DATE This transaction was refused as the APP program is not active for this date of service.
98EINVALID PAY-TO CODE This transaction was refused as the pay-to code must be "BAPY" (BA Payee)for all APP services.
98EAINVALID HEALTH SERVICE CODE - NON PATIENT-SPECIFIC UNIQUE LIFETIME IDENTIFIER This transaction was refused as only HSCs that are defined as non patient-specific may be submitted under the non patient-specific ULI.
98EBINVALID BUSINESS ARRANGEMENT NUMBER This transaction was refused as the APP BA number must be used for all services listed as other interventions.