AHCIP billing can be complicated. However, having a better understanding of the different modifiers and premiums available in the Alberta Health schedule of benefits can help you optimize your billings and minimize billing errors and rejections.
In this blog post, we go back to basics and provide a guide on how to bill AHCIP billing codes correctly to make sure you are getting paid for the care you are providing.
Alberta Payment Models
In Alberta, there are different ways in which physicians get paid for the services they provide including the traditional fee-for-service model and Alternative Relationship Plans.
The traditional fee-for-service model requires a physician to submit a claim for every service they provide. They will then be compensated appropriately for the service by the Ministry.
Alternative Relationship Plans
Alternative Relationship Plans (ARP) is another method that physicians can be compensated. There are three different kinds of clinical ARP models: annualized, blended capitation, and sessional.
- Annualized Model: The annualized ARP compensation model is based on the number of physician full-time equivalents required to deliver the clinical services within the clinic ARP. For more information on the annualized model, read here.
- Blended Capitation Model: The Blended Capitation model compensates family doctors based on how many patients they have, and the number of services provided. For more information on the blended capitation model, read here.
- Sessional Model: Sessional Clinical ARP compensation is based on an hourly rate for the delivery of direct and indirect clinical services within an organized program to a defined patient group by a physician. For more information on the sessional model, read here.
Alberta Health Billing Codes
Regardless of what compensation model you are in, all physicians practicing in Alberta are required to submit billing codes or Health Services Codes (HSCs) for any medical services they provide to their patients. Services include visits, procedures, tests, or medical discussions.
How to Submit a Claim
AHCIP works on a weekly payment schedule. The cut-off date is every Thursday at 4:30 pm and payment is typically paid one week later for any claims submitted prior to the Thursday cut off. Here are the basic steps on how to submit a claim to the Ministry:
- Fill in information about you and the patient you provided a medical service to.
- Your practitioner identification number (PRAC ID).
- The personal health number of the patient.
- If applicable, the PRAC ID of the referring practitioner.
- Indicate the service that was provided.
- Enter the appropriate health service code, plus any applicable modifier code(s).
- Indicate where the service was provided.
- Enter the facility number.
- If the facility is an office or non-hospital surgical facility, leave the functional centre field blank.
- If the facility is a general (active treatment) hospital, auxiliary hospital, or nursing home, enter a functional centre code.
- Indicate the date and time when the service took place.
- Enter the date of service.
- If applicable, add the modifier for the time of day.
- For time-based services, enter the number of calls required to determine the units of time involved.
- Indicate why the procedure was done.
- For the Alberta Health Diagnostic Code Supplement (ICD-9), enter the code(s) for the disease, condition or purpose related to the medical service you are claiming.
Physicians have 90 days from the date the health service was provided to submit a claim. We recommend staying on top of your billings as submitting your claims to AHCIP on time is very important to make sure you get paid for the services you provide.
If you need any assistance with submitting your billings to the Ministry, feel free to contact us.
All claims must have an action code to indicate if it is a new claim or a resubmission of a previously processed claim. Here are the four valid action codes:
|Action Code||Description||When to Use|
|A||Add||To submit a claim for the first time or resubmit a claim that was refused.|
|C||Change||To change the information on a claim.|
|R||Reassess||To submit a previously processed claim that was reduced in payment or paid at zero and you wish to have it reassessed with additional supporting information you are now providing.|
|D||Delete||To delete a claim that was previously paid in full, reduce or paid at zero.|
Modifiers are used to increase a claim amount for a specific reason. Modifiers can be either explicit or implicit, meaning that they can be entered by the physician (explicit) or by the AHCIP claim processing system (implicit).
Fee codes can have up to three modifiers that change the value of the code based on the role of the physician, when the service was provided, the complexity of the patient/services and the time spent with the patient.
Common modifiers include those for additional time spent on patient care (charting, lab results, etc.) or time spend with patients after hours.
CMGP: Complex Patient Visit
The CMGP modifier is used to indicate a complex patient visit where the physician spends 15 minutes or more on management of the patients care.
- +1 unit for each additional 10 mins after the first 15 mints
- CMGP03 indicates a physician has spent a minimum of 35 minutes on the patient (1 unit for 15 mins, 2 units for the next 20)
- A maximum of 10 units may be claimed
- May only be claimed by general practitioners for HSCs 03.01J, 03.03A, 03.03AZ, 03.03B, 03.03BZ, 03.03C, 03.03N, 03.03NA, 03.03NB, 03.03P, 03.03Q, 03.07A, 03.07AZ, 03.07B
- For each unit claimed, increase fee by flat amount
CMXC30: Complex patient Consultation/Visit
This modifier is used to indicate a complex patient visit where the physicians spends 30 minutes or more on management of the patients care.
- May only be claimed for HSCs 03.04A, 03.04AZ, 03.04B, 03.04C, 03.04D, 03.04E, 03.04F, 03.04FA, 03.04G, 03.04GA, 03.04H, 03.04HA, 03.04M, 03.08A, 03.08AZ, 03.08B, 03.08BZ, 03.08C, 03.08F, 03.08H, 03.08K and 03.09A.
After Hours Time Premium
The After Hours Time Premium can be billed in addition to other codes you are billing to account for working after hours – for example, a shift premium. To bill for the premium, you must bill the fee code 03.01AA with a modifier indicating the time of day you worked and the number of calls made (15 minutes per call).
Here are the time premium codes with the max number of units you can make per day:
|TEV||Evening, weekdays (17:00 – 20:00)||Max 20 units/day|
|TNTP||Nighttime PM, everyday (22:00-24:00)||Max 8 units/day|
|TNTA||Nighttime AM, everyday (24:00-07:00)||Max 28 units/day|
|TWK||Weekend (07:00-22:00)||Max 60 units/day|
|TST||Statutory Holiday (07:00-22:00)||Max 60 units/day|
|TDES||Designated Holiday (07:00-22:00)||Max 60 units/ day|
Note: Each unit is equal to 15 minutes. You may only bill a maximum of four-time premium codes per eligible hour.
Virtual Care / Telehealth Billing
Due to the COVID-19 pandemic, the Ministry introduced new virtual billing codes to allow physicians to continue providing care over telephone and video conference. We have written a detailed Guide to Alberta Medical Billing Codes for Virtual Care with tips on how to best bill for these services. You can read the full blog here.
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