Pdf alberta health claims submission explanation codes

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Alberta Health Claims Submission Explanation Codes

01 NOT REGISTERED 01 We have no record of this person registered with this Personal Health 01 Number.

01A NOT REGISTERED 01A This person is not registered under the Alberta Health Care Insurance Plan. 01A If the patient is a newborn, submit a new claim with a person data segment 01A and the appropriate newborn code.

01B NON RESIDENT 01B We cannot confirm that this patient is a resident of Alberta. Please 01B contact the patient to obtain the correct billing information.

01C GOOD FAITH CLAIM 01C Payment has been refused as: 01C a) A Good Faith claim was previously paid for this patient; therefore, this 01C patient does not qualify for further Good Faith claim processing, or 01C b) Good Faith claims are not payable for visitors to Alberta or for 01C residents covered by the federal government, such as RCMP, Canadian 01C Forces members or inmates in federal corrections facilities. 01C Refer to the practitioner resource guide for information regarding your 01C billing alternatives.

02 REGISTRATION NUMBER/PHN CONFLICT 02 The Health Registration Number and the Personal Health Number (PHN) used 02 are not for the same person.

03 NEWBORN 03 The claim was refused as the Plan is unable to contact the parent(s) of this 03 child to confirm registration.

04 DONOR'S REGISTRATION NUMBER USED 04 Submit this claim using the Personal Health Number of the donor recipient.

04A CHANGED PERSONAL HEALTH NUMBER 04A This is the correct Personal Health Number for this patient. All new claims 04A for this patient should be submitted with this number.

05 PATIENT PERSONAL HEALTH NUMBER - NOT EFFECTIVE 05 This Personal Health Number is not effective for the date(s) of service.

05A INVALID PERSONAL HEALTH NUMBER 05A The Personal Health Number is invalid or blank.

05AA OPTED OUT RESIDENTS 05AA The patient has opted out of the Alberta Health Care Insurance Plan. The 05AA patient has agreed to assume financial liability for all health services. 05AA Please contact your patient regarding payment for your services.

05B UNREGISTERED WCB CLAIM 05B The patient is not eligible for Alberta Health Care coverage for the date(s)

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05B of service. Submit your claim directly to the Workers' Compensation Board.

05BA INVALID/BLANK REGISTRATION NUMBER 05BA This claim has been refused as the registration number is: 05BA (a) blank 05BA (b) invalid

05BB INVALID/BLANK ULI 05BB This claim has been refused as the Unique Lifetime Identifier is: 05BB (a) blank 05BB (b) invalid 05BB (c) not a valid ULI for the Service Recipient

05C ELIGIBILITY EXTENDED HEALTH BENEFITS PROGRAM 05C The patient did not have coverage under the Extended Health Benefit (EHB) 05C program on this date. 05C Effective April 1,2002, to be eligible for EHB the patient must be a 05C recipient of the Alberta Widows' Pension or their dependant. 05C If your patient does not fit this description, benefits will be refused. 05C If the patient needs more information, contact Customer service and 05C Registration Branch at (780)427-1432.

05E E.H.B. COVERAGE 05E Payment has been refused as the service(s) were provided when the patient 05E did not have coverage under the Extended Health Benefits Program.

06 RETROACTIVE ELIGIBILITY CHANGE 06 Your request to change or reassess this claim was refused. Due to a 06 retroactive eligibility change, the patient is not eligible for Alberta 06 Health Care coverage for this date of service. 07 NEW RECIPIENT FOR ALTERNATIVE PAYMENT PLAN CONTRACT 07 Your claim for a new recipient was paid as a fee for service benefit.

08 NEW RECIPIENT PREVIOUSLY PAID FOR APP CONTRACT 08 Payment was refused as a fee for service claim was previously paid for a 08 new recipient. 09 INITIAL ROSTER RELATIONSHIP 09 Payment was refused as an Initial Roster relationship exists for this 09 patient. Therefore, a fee for service claim is not payable under a Temporary 09 Roster relationship.

10 INELIGIBLE PRACTITIONER/INCORRECT SUBMISSION 10 We have not received notification from the Governing Body/Licensing 10 Association that the Practitioner is accredited to perform this service.

10A SERVICE PROVIDER RESTRICTIONS 10A Our records indicate that the Service Provider is: 10A (a) restricted to a specific Facility or 10A (b) restricted to performing specific services.

10AA INELIGIBLE PRACTITIONER 10AA This claim has been refused as you are not entitled to payment for this 10AA type of service.

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11 LOCUM BUSINESS ARRANGEMENT 11 This claim has been refused as the Business Arrangement does not include 11 a Business Arrangement Type of Locum.

20 INELIGIBLE SERVICES 20 Payment was refused as the services are not covered in the Schedule of 20 Benefits. The services include: 20 Advice by Telephone 20 Ambulance Service 20 Anaesthetic Materials 20 Cosmetic Services 20 Drugs/Agents 20 Medical and Surgical Appliances and Supplies 20 Medical Testimony in Court 20 Oculo-visual/Optometric services for residents age 19 through 64 years (For 20 dates of service on or after December 1, 1994) 20 Secretarial or Reporting Fees 20 Stand by Time 20 Tinted Glasses (EHB) 20 Travel Time 20 Refer to the General Rule 3 in the Schedule of Medical Benefits or General 20 Rule 5.1 in the Schedule of Oral and Maxillofacial Surgery Benefits.

20A THIRD PARTY SERVICES

20A Examinations or services required to provide reports or certificates

20A requested by a third party are not an insured service, eg:

20A Adoption

Judicial Purposes

20A Attendance at Camp

(examinations/procedures

20A Autopsies

requested by police)

20A Employment

Motor Vehicle License (except

20A Insurance/disability

after the age of 74.5 years of age)

20A Family & Social Services

Participation in Sports

20A University or other school Passport or Visa

20A entrance

Immigration Requirements

20AB EXPERIMENTAL/RESEARCH SERVICES 20AB Payment was refused as the Alberta Health Care Insurance Plan does not pay 20AB benefits for services that are experimental and/or in the research stage.

20B R.C.M.P., ARMED FORCES AND FEDERAL PENITENTIARY 20B Members of the RCMP, Armed Services and inmates of a Federal Penitentiary 20B are not beneficiaries under the Plan.

20C PRACTITIONER BILLING FOR OWN FAMILY 20C Services provided to members of your family or yourself are not a benefit 20C under the Plan.

20D DENTAL CARE - ORAL SURGERY 20D This service is not an oral surgical procedure payable by the Plan.

20E BENEFIT GUIDE 20E This is an incorrect Health Service Code. Please refer to the Plan's 20E appropriate fee schedule.

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20F EXCLUDED ITEM 20F This service is not payable under the Extended Health Benefits Program.

21 WORKERS' COMPENSATION BOARD CLAIM 21 This claim is the responsibility of the Workers' Compensation Board.

21A PAYMENT RESPONSIBILITY/BENEFIT CODE 21A The payment responsibility (Workers' Compensation Board or Alberta Health 21A Care) and Health Service Code submitted do not agree. Verify the 21A responsibility and submit a new claim.

21AA WORKERS' COMPENSATION BOARD - PATIENT OVER 14 YEARS 21AA The patient must be 14 years of age or older to qualify for a Workers' 21AA Compensation Board claim.

21AB WORKERS' COMPENSATION BOARD CLAIM SUBMISSIONS 21AB Payment was refused as effective June 1, 2000 Workers' Compensation Board 21AB claims are to be submitted directly to the Workers' Compensation Board.

21B WORKERS' COMPENSATION BOARD (OUT OF PROVINCE) 21B This claim is the responsibility of another Province's Workers' Compensation 21B Board. Please submit the claim directly to the appropriate Workers' 21B Compensation Board.

22 INELIGIBLE PATIENT 22 Our records indicate this claim is the responsibility of another Provincial 22 Medical Plan.

23 CONTRACT SERVICES 23 This service is payable only to practitioners who provide medical services 23 under a written agreement with the Department of Health.

23A PRIOR APPROVAL 23A Payment was refused as: 23A (a) this service requires prior approval from the patient's Provincial 23A Medical Plan and/or 23A (b) prior approval was not received for this date of service.

24A PODIATRY SERVICES ONLY PAYABLE IN OFFICE FACILITY 24A This service is only payable when performed in an office.

25 EXCLUDED SERVICE - RECIPROCAL PROGRAMS 25 Payment has been refused as this service is excluded according to the 25 Reciprocal Agreement. Your claim should be billed directly to the patient 25 or, if applicable, their home provincial health plan.

25A MEDICAL RECIPROCAL - INCORRECT CLAIM 25A Payment was refused as you have submitted a Medical Reciprocal claim for 25A services provided to an Alberta patient.

28 OPTED OUT PRACTITIONER 28 This service was provided by a Practitioner who has opted out of the 28 Alberta Health Care Insurance Plan and there is no indication that this 28 was an emergency service.

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28 INCOMPLETE CLAIMS/ADDITIONAL INFORMATION REQUIRED

30 ADDRESS 30 This claim was refused as the Address on the Person Data Segment is invalid, 30 incomplete or blank.

30A PROVINCE CODE 30A This claim was refused as the Province Code on the Person Data Segment is 30A invalid, incomplete or blank.

30AA CITY NAME 30AA This claim was refused as the City Name on the Person Data Segment is 30AA invalid, incomplete or blank.

30AB COUNTRY CODE 30AB This claim was refused as the Country Code on the Person Data Segment is 30AB invalid, incomplete or blank.

30AC POSTAL CODE 30AC This claim was refused as the Postal Code on the Person Data Segment is 30AC invalid.

30B DATE OF BIRTH 30B This claim was refused as the Date of Birth on the Person Data Segment is: 30B (a) blank 30B (b) invalid 30B (c) incomplete 30B (d) after the date of service

30BA GENDER 30BA This claim was refused as the Gender on the Person Data Segment is invalid 30BA or blank.

30E SURNAME 30E This claim was refused as the Surname on the Person Data Segment is invalid 30E or blank.

30EA FIRST NAME 30EA This claim was refused as the First Name on the Person Data Segment is 30EA invalid or blank.

30EB MIDDLE NAME 30EB This claim was refused as the Middle Name on the Person Data Segment is 30EB invalid or blank.

30F PERSON TYPE 30F This claim was refused as the Person Type on the Person Data Segment is 30F invalid or blank.

30G GUARDIAN/PARENT PERSONAL HEALTH NUMBER 30G This claim was refused as the Guardian/Parent Personal Health Number on the 30G Person Data Segment is invalid or blank.

30H GUARDIAN/PARENT HEALTH PLAN NUMBER

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30H This claim was refused as the Guardian/Parent Health Plan Number on the 30H Person Data Segment is invalid or blank.

31 INCOMPLETE PERSON DATA

31 This claim has been refused as the Person Data Segment is:

31 (a) required

31 (b) incomplete for the Person Type submitted

31 (c) required as we have no record of the Personal Health Number which was

31

submitted.

31A PERSON DATA SEGMENT CONFLICT 31A The Out of Province registration number and the Person Data Segment do not 31A match the service recipient information in our files. 31A Confirm the patient's Out of Province health care card registration number, 31A home province/recovery code, and personal data information with the patient 31A or the patient's home provincial health plan. If applicable, submit a new 31A claim with supporting text indicating that the physician has verified the 31A patient's personal information.

34AA CLAIM CURRENT YEAR SEGMENT 34AA The current year indicated within the claim number is not numeric or not the 34AA current year.

34AB CLAIM SEQUENCE NUMBER 34AB The claim sequence number indicated within the claim number is not numeric.

34AC CLAIM CHECK DIGIT 34AC The check digit number indicated within the claim number is invalid.

34AD ACTION CODE 34AD The action code is inconsistent with other information segments within this 34AD transaction.

34B EMSAF INDICATOR 34B The EMSAF (Extraordinary Medical Services Assessment Fund) indicator is 34B invalid.

34C CLAIM RECORD TYPE 34C The record type is invalid. To process the claim the record type must be: 34C (a) number 2 in the (batch header) data field 34C (b) number 3 in the (claim detailed record) field 34C (c) number 4 in the (batch trailer) data field 34C Refer to the Electronic Claims Submissions Specifications Handbook.

34DA CLAIM TRANSACTION TYPE 34DA The transaction type is not CIPI. 34DA Refer to the Electronic Claims Submissions Specifications Handbook.

34DB CLAIM SEGMENT TYPE 34DB The segment type must be: 34DB (a) CIBI - claim regular or 34DB (b) CPDI - person data segment or 34DB (c) CSTI - text segment or 34DB (d) CTXI - text cross reference segment or

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