In the past few months, we’ve seen a big uptick in Alberta Health claim rejections due to invalid health care. In this post, we’re going to provide an overview of AHCIP ‘invalid healthcare’ rejections, how you can confirm the type of coverage your patient has, and how to get any rejected claims paid.
We’re seeing two new causes of invalid healthcare. Earlier this year, the Alberta Government removed good faith claims. Physicians could previously make claims for patients they reasonable believed were Alberta residents, but now physicians must confirm valid Alberta Healthcare insurance. We’re also seeing invalid healthcare rejections for patient’s in the process of moving from work visas to permanent residency. They are experiencing unusual delays in either getting access to apply for AHCIP or having their AHCIP application processed.
The Alberta Health Care Insurance Plan (AHCIP) provides healthcare to eligible Alberta residents. Eligible means you are legally entitled to remain in Canada and make Alberta your home, you are committed to staying in Alberta for 183 days in a 12 month period, you are not claiming residency elsewhere, or you are otherwise deemed to be a resident or temporary resident by the regulations. For individuals moving from another country or province, there can be a waiting period to become eligible under AHCIP.
There are some Alberta residents who are non-eligible. This includes Canadian Armed Forces, federal penitentiary inmates, refugee claimants, refused or failed refugee claimants, and people with expired immigration documents. Some of these are covered by healthcare insurance from the federal government. Visit the Alberta governments website for complete information on eligibility (https://www.alberta.ca/ahcip-eligibility.aspx).
There are a variety of methods to check your patient’s healthcare coverage:
1. Patient Stickers and Hospital Admission Sheets: A patient’s healthcare insurance coverage is usually printed on the patient sticker or hospital admission sheet. For examples, check out an an earlier blog post we did that covers what these stickers look like (https://statgo1.wpengine.com/blog/5-tips-to-improve-your-ahcip-medical-billing/). Patient stickers and admission sheets can occasionally be incorrect, so a patient’s coverage should be verified using one of the methods below.
2. Alberta Health Phone Line: Alberta Health has an Interactive Voice Response number (1-888-422-6257) that allows physicians to check if a patient has valid Alberta Health coverage. Call the number, enter the patient’s ULI and the date of service, and you will get an automated response informing you if the patient has valid Alberta Healthcare as of the date of service. Note the response is specific to the date of service entered. If you patient receives valid AHCIP coverage as of September 1, but the date of service was August 31, the system will notify you that coverage does not apply.
3. Netcare: The best source on a patient’s government health insurance is Netcare. Physicians can view the patient’s demographic details and what insurance is valid. For each patient, an eligibility start date is shown. If this date is blank, the patient does not have Alberta Health insurance. As noted above, compare the date of service with the eligibility start date to check if your patient had AHCIP coverage for the date of your claim.
Before we jump into how to check for non-Alberta government coverage, it’s important to understand healthcare numbers for patients. Every patient in Alberta is given a Unique Lifetime Identifier (ULI) number. If they have Alberta Health coverage, this ULI number is the same as their Personal Healthcare Number (PHN). But if the patient has out-of-province coverage, the ULI and PHN will be different. Some patient stickers will show the ULI number and then the province of health coverage. If the sticker has ‘AB’ for Alberta, the patient has AHCIP coverage. If the sticker has ‘BC’ for British Columbia, the patient has out-of-province coverage and you need to go to Netcare to get their BC PHN and other details to submit the claim.
If you get an ‘invalid healthcare’ rejection from Alberta Health, your patient could be covered by some form of government insurance that will pay the claim. For physicians practicing in Alberta, there are 5 broad categories to be aware of:
Eligible for AHCIP, but not coverage is not active:
If your patient doesn’t have active Alberta Health coverage, it doesn’t mean they are not eligible for coverage. Eligible patients can have AHCIP coverage instated retroactively to cover their service date. This requires the patient to apply for coverage at their local registry or online.
Worker’s Compensation Board (WCB):
Alberta Health will not reject claims as ‘invalid healthcare’ for claims that should have been submitted to WCB. If you were not aware at time of service that your patient has a workplace related injury, Alberta Health will pay the claim. It is likely in the future when Alberta Health audits these claims, the claim will be reversed and Alberta Health will indicate the claim is under the purview of WCB.
Out-of-province (OOP):
Physicians can confirm out of province healthcare on the patient sticker, patient admission sheet, or on Netcare. The patient sticker may show the patient’s province of health care next to the ULI number. If you see another province (eg ‘BC’ for British Columbia), you know have a patient with out-of-province care and you need to submit the claim accordingly. On Netcare, out-of-province coverage is noted on the bottom half of the patients details page. Additional patient demographics required for out-of-province claims are also indicated: (middle name if indicated, sex, date of birth, full address). Out of province claims are submitted to Alberta Health (with additional information) and paid by Alberta Health. Note that Quebec has opted out of the provincial agreement on out-of-province claim payment, and Quebec claims must be submitted like private claims directly to the insurer.
Federal government coverage:
Patients with federal government coverage (Department of National Defense, RCMP, federal inmates, refugees) will have their relevant insurance coverage indicated on their hospital admission sheet. Federal government coverage will not be indicated in Netcare. If you are uncertain if a patient has federal government healthcare coverage, you can check by pulling the patients chart or by confirming with the referring physician. For patients with federal healthcare, billing claims must be submitted to Medavie Blue Cross or to the specific penitentiary as appropriate.
Private coverage or out-of-pocket:
If your patient does not have any type of government healthcare coverage, then they can provide you with private healthcare coverage or pay out of pocket. For private procedures, it is advisable to collect payment before hand. The AMA provides a non-public document with suggested rates to help you price the service. If you are an AMA member, you can access this document through the AMA website. Statgo can also help you with issuing invoices, following up on payment, and processing payments.
Getting an “invalid healthcare” rejection paid can take some legwork, but it’s financially worth it. If you don’t have the time to do the administration, Statgo can manage the process for you and get the claims paid. Here are the steps to get your claim paid:
1. Check if the patient has other insurance: You’re getting an “invalid healthcare” rejection from Alberta Health because the patient doesn’t have valid AHCIP coverage for the claim’s date of service. The first step is to check if the patient has out-of-province or federal coverage. Use the guide above to check if the patient has other government coverage. If so, resubmit the claim accordingly.
2. Advise eligible patients to register for AHCIP coverage: Before issuing a private invoice, check if the patient is eligible for Alberta Healthcare coverage. You can contact the patient, advise them you cannot find valid coverage for them, and if appropriate, advise them to have coverage instated by going to their local registry. Statgo can help you with contacting patients and advising them on the process to get AHCIP coverage.
3. Issue a private invoice: If the patient doesn’t have coverage, you can issue a private invoice. Statgo can also help you with issuing invoices, following up on payment, and processing payments.
We hope this guide is valuable to avoiding ‘invalid healthcare’ rejections and for getting rejections you do receive paid. Many physicians give up on invalid healthcare rejections – don’t do this! It is financially worth your time to get them paid. If you don’t have the time (or energy) to track them down, we’re happy to help. As always, if you have any questions or comments about this post or your billing in general, please get in touch!