As of August 1st, 2021, the General Preamble has been amended for expansions to sections A.2vi and C.5. These expansions apply to completing either a ‘Pharmacare Required Special Authority Request’ or a ‘Pharmacare Plan G Form’ included in any consultation, visit, or service.
A.2. Introduction to the General Preamble
The service you claim needs to include the following components unless otherwise specified. Payment for these benefits is included in the listed fees.
Your patient, or their representative, must be informed and provided with advice and information about their condition and recommended therapy. This includes advice regarding any related assessments, procedures and/or therapy. The advice and information you provide or provision of prescriptions cannot be claimed additionally. This includes completing Pharmacare required Special Authority requests or Pharmacare Plan G forms. Additional claims cannot be made for diagnostic and laboratory requisitions either unless your patient’s condition requires further review and assessment to provide advice.
C.5. Inclusive Services and Fees
Claims for your patient to be personally reassessed (before renewing their prescription, specialty referral, release of diagnostic or laboratory results, etc.) that are not medically necessary can’t be made to MSP. Even if you choose to see your patients personally or speak with them over the phone, you cannot claim these services.
You will not be paid for completing ‘Pharmacare required Special Authority requests’ or ‘Pharmacare Plan G forms’ as they are included as part of a visit, consultation, or service.
Most surgical procedures, the critical care per diem listings, and some obstetrical listings have fees that are meant to cover multiple services provided over longer periods of time.
MSP gives circumstantial consideration to claims that require additional care, because of complications or non-related illnesses, beyond what is usually included in the listed service. In these situations, you must provide sufficient explanation along with your claim.
Familiarizing yourself with the Payment Schedule and preambles will ensure you’re claiming for your services correctly, and therefore getting paid as expected. Knowing the ins and outs of the sections that apply to you will prevent you from committing errors resulting in delayed or declined payments. If you have any questions about these amendments, feel free to reach out to our team.
This article offers general information only and is not intended as legal, financial or other professional advice. A professional advisor should be consulted regarding your specific situation. While information presented is believed to be factual and current, its accuracy is not guaranteed and it should not be regarded as a complete analysis of the subjects discussed. All expressions of opinion reflect the judgment of the author(s) as of the date of publication and are subject to change. No endorsement of any third parties or their advice, opinions, information, products or services is expressly given or implied by RBC Ventures Inc. or its affiliates.