Navigating AHCIP Good Faith Claims: A Guide for Alberta Physicians in 2024

October 1, 2024

The Alberta Government previously announced that physicians will be able to submit good faith claims for April 1, 2022 dates of service and on but that the submission process was being designed. The Alberta Government has now released a new bulletin (GEN 145) detailing how physicians can submit good faith claims. The Alberta Healthcare Insurance Plan (AHCIP) bulletin details both how physicians can submit good faith claims and the rules they must abide by when doing so.

In this blog post, we’re going to review how physicians can submit good faith claims, which patients are eligible for good faith, the rules physicians must be adhered to when confirming a claim qualifies as good faith, and patient types who are not eligible for good faith claims.

Who is eligible for good faith claims?

Broadly speaking, there are 2 patient types who are eligible for good faith claims:

Alberta patients who are “residents” of Alberta for the purposes of registration and coverage under AHCIP but cannot provide proof of residency or registration with AHCIP because they lack the usual identification (driver’s license, proof of fixed address, etc.).

Out of province patients who are covered by their home province/territories health insurance plan, but did not present a valid and active health insurance card.

Who is excluded from good faith claims?

There are a variety of patient types who are excluded from good faith claims and should be billed to the appropriate insurance provider or privately. These are patients are:

WCB patients. These patients should be billed to Alberta WCB.

Federal Penitentiary Inmates. These patients should be billed directly to the federal government or institution.

Members of the Canadian Armed Forces (CAF). These patients should be billed to Medavie Blue Cross.

Refugees. These patients are covered under the Interim Federal Health Program (IFHP) and should be billed to Medavie Blue Cross

Patients insured by RAMQ / Province of Quebec. These patients should be submitted to RAMQ.

Individuals who have chosen to opt out of AHCIP. These patients should be billed privately.

Non-residents of Canada (tourists, those not legally entitled to remain in Canada). These patients should be billed privately.

Out of province patients with unproven coverage seeking medically required services in Alberta that are not covered by the Medical Reciprocal Agreement. These services should be billed privately and the patient can seek reimbursement in their home province. The physician can provide the patient with form: Out-of-Province Claim Physician or Practitioner Services (gov.ab.ca)

Temporary Residents (students, foreign workers and their dependents) with an Alberta health care card past expiry date. These patients should be billed privately.

Ukrainian nationals who entered or remain in Alberta or Canada due to the armed conflict in Ukraine. These patients are required to be registered under the Government of Alberta’s Ukrainian Evacuee Temporary Health Benefits Program (UETHBP). AHCIP must receive a valid and active PHN issued under the UETHBP. These patients cannot be billed under good faith even if they are eligible for an Alberta PHN under the UETHBP

What steps are required to confirm a patient is eligible for good faith billing?

Physicians must complete the following to verify if a patient has valid and active AHCIP coverage, checking the patient/PHN on:

1. Alberta Health Interactive Voice Response (IVR) – 1-888-422-6257. This number allows physicians to enter a PHN and receive a confirmation if a PHN is valid and active for the date of service being claimed.

2. Alberta Netcare. This enables a physician to verify if a patient’s PHN is valid and active for the date of service. It will also allow a physician to confirm the required demographics for the patient if the claim is submitted as a good faith claim.

3. The facilities’ Admission, Discharge, Transfer (ADT)/Clinical Information System (CIS) systems
(Connect Care, Meditech, etc.) to verify if a patient’s PHN is valid and active.

4. The facilities’ registration area and/or health records department, with which physicians and their staff
can connect directly, which will provide the patient’s valid and active PHN.

If the above are unsuccessful in confirming AHCIP coverage, the physician should direct the patient to call the AHCIP General Inquiries line at 780-427-1432 within Edmonton or for the rest of Alberta toll-free to 310-000, then 780-427-1432. The agents here can assist the patient in confirming their status, update records, or send out an application for coverage.

What proof do I need to show I determined a patient was eligible for good faith?

The bulletin states that physician must, if requested:

“provide to Alberta Health any of the information they relied on to conclude the patient was a resident or had active P/T Plan coverage notwithstanding the lack of usual identification” and

“in respect of patients who are residents, the physician or their staff or facility staff has informed
the patient how to register under the AHCIP.”

The requirements are a bit unclear to us, but we recommend physician document the steps they took according to the verification requirements above and the dates on which they performed those checks.

How do I submit a good faith claim?

The submission process should be like any other AHCIP or out of province claim on your billing software, except that you must clearly identify the claim as a good faith claim and provide the patient demographics and address. The demographic requirements are:

Last Name (Surname)

First Name

Date of Birth

Gender

Complete address including postal code (For Address: Do not use dashes, abbreviations or punctuation, or the claim will be refused (e.g., 4156 Northview Crescent Calgary AB CAN T1X 1M9)

If you bill with Statgo, you will select claim type as “Good Faith” when entering a claim.

Does the 90 day rule apply to good faith claims?

For the insured medical services provided between April 1, 2022 and February 6, 2024, AHCIP has stated that the 90-day rule for claims submission in that section does not apply. However, it is not clear to us if there is a limit of 90 days from the bulletin to submit these claims or if there will be some other future date limitation. It is implied in the bulletin that for dates of service after February 6, 2024, the 90 day submission limitation will apply to good faith claims.

AHCIP Bulletin Link

For more information, Please review the AHCIP bulletin link for reference: https://open.alberta.ca/publications/bulletin-alberta-health-care-insurance-plan-general-information

Summary

The return of good faith claims is good news for Alberta physicians and will allow physician to collect payment for patients that would otherwise be eligible for Canadian provincial healthcare coverage but cannot provide that coverage or be registered for a variety of reasons. We’ll continue to post further updates as new information becomes available to us.

As always, please let us know if you have any questions of comments!