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    Governing Rule: 1


    This document, entitled the Schedule of Medical Benefits is hereinafter referred to as "Schedule". This Schedule applies only to those services that are insured under the Alberta Health Care Insurance Act. These General Rules (GRs) apply to all benefits unless otherwise stated.

    • 1.1

      In this Schedule, "certificate of registration" means a health insurance card issued under the Health Insurance Premiums Act to a resident of Alberta, or any other document prescribed as a "certificate of registration" for the purposes of the Health Insurance Premiums Act and the Medical Benefits Regulation.

    • 1.2

      "holidays" or "statutory holidays" means New Year's Day, Family Day, Good Friday, Victoria Day, Canada Day, Alberta Heritage Day, Labour Day, Thanksgiving Day, Remembrance Day, Christmas Day, Boxing Day;

    • 1.3

      where a holiday falls on a Saturday or Sunday the Minister shall designate another day as the holiday;

    • 1.4

      "physician" includes "osteopath";

    • 1.5

      "benefit year" means July 01 of one year to June 30 of the following year.

    • 1.6

      For the purposes of billing home visits, "home" includes personal residence or temporary lodging, assisted living, designated assisted living, group home, seniors' lodge, personal care home and other residences as approved, but does not include auxiliary hospitals or nursing homes.

    • 1.7

      A physician's "family" means children, grandchildren, siblings, parents, grandparents, spouse or adult interdependent partner or any person who is dependent on the practitioner for support in accordance with the Alberta Health Care Insurance Regulation.

    • 1.7.1

      A patient's "family" means children, siblings, parents, legal guardian/agent (agent as defined in the Personal Directives Act (RSA 2007c37s3)), spouse or adult interdependent partner.

    • 1.8

      "Home Care Worker" is defined as a registered: nurse, licensed practical nurse, psychiatric nurse, occupational therapist, physiotherapist, respiratory therapist, or any other health profession working in an Alberta home care program or Alberta palliative care program administered by a regional health authority.

    • 1.9

      "Community Mental Health Care Worker" is defined as a registered: nurse, licensed practical nurse, psychiatric nurse, social worker, psychologist or any other health profession working in an Alberta community mental health care program administered by a regional health authority.

    • 1.10

      "Telehealth" service is defined as a physician delivered health service through the use of videotechnology, including store and forward, that is provided to a patient who is in attendance at a regional health authority telehealth site or a registered Health Canada health centre or nursing station site at the time of the video capture. Telehealth services do not include teleradiology. The physician must provide the service at a regional

      health authority telehealth site or a registered Health Canada health centre or nursing station site in order to submit a claim.

    • AMA billing tips:

      • The TELES modifier may only be claimed when providing services at a regional telehealth site or registered Health Canada Telehealth location. The use of SKYPE or any other secure video transfer system may not be claimed using the TELES modifier. Only services provided using regional or Health Canada telehealth equipment may be claimed using the TELES modifier. The TELES modifier is NOT to be claimed for services provided via telephone.

    • 1.11

      "Videotechnology" means the recording, reproducing and broadcasting of visual images.

    • 1.12

      "Store and forward" is defined as a system that provides the ability to capture and store text, audio, static and video images and forward them for the review and opinion of a physician.

    • 1.13

      "Rotation Duty" means

      • scheduled hospital emergency department duty providing on-site emergency department physician coverage or physicians providing first call coverage for an emergency department with greater than 25,000 visits per year or;
      • scheduled on-site coverage in a facility designated by Alberta Health as an AACC or UCC.
    • 1.14

      Unless otherwise stated, the term "encounter" used in this Schedule means each separate and distinct time a physician provides services to a patient in a given day as defined in GR 1.19. To be recorded as separate encounters, multiple services provided to a patient may not be initiated by the physician, or may not be a continuation of a service which began earlier in the day. An example of continuation of services is the time spent with a patient to review x-ray or laboratory results ordered during an examination of the patient earlier in the day. If the patient initiates the second and subsequent encounter(s) or the physician is requested to attend the patient by hospital or nursing home staff, additional encounters may be claimed.

    • 1.15

      "Conceptual age" is defined as the estimated gestational age from the actual time of conception. It is usually considered to be at least 14 days after the first day of the last menstrual period.

    • 1.16

      "Neonate" is defined as a newborn infant up to and including 30 days of age.

    • 1.17

      "Resident of Alberta" means a person lawfully entitled to be or to remain in Canada, who makes the person's home and is ordinarily present in Alberta and any other person deemed by the AHCIP regulations to be a resident, but does not include a tourist, transient or visitor to Alberta.

    • 1.18

      "Home visit" means a visit by a physician to provide care for a patient in their home.

    • 1.19

      "Day" means a period of 24 hours starting at midnight.

    • 1.20

      "Medical learner" means a supervised physician in training.

    • 1.21

      "HSC" means Health Service Code.

    • 1.22

      "AACC" means Advanced Ambulatory Care Centre.

    • 1.23

      "UCC" means Urgent Care Centre.

    • 1.24

      "CPSA" means College of Physicians and Surgeons of Alberta.

    • 1.25

      "Corrected age" means the chronological age reduced by the number of weeks born before 40 weeks of gestation.

    • 1.26

      Telecommunications means communication via telephone, facsimile or email.

    • 1.27

      When claiming for telecommunication and telephone call services, the location of the physician at the time of the service should be used on the claim.

    • 1.28

      "Regional facility" means any facility owned and operated by Alberta Health Services.

    • 1.29

      "Weekend(s)" means Saturday and Sunday.

    • 1.30

      "Calendar week" means a period of seven consecutive days beginning with Sunday and ending with Saturday.

    • 1.31

      "Active Practice" is defined as a physician that has fulfilled both of the following criteria in the previous 12 months:

      1. 5 or more procedures where the physician is acting as the primary surgeon AND
      2. the physician has submitted claims and provided at least 10 or more of either or any combination of the following HSCs: 03.03A, 03.07A, 03.07B or 03.08A.
    • 1.32

      "Mobile Integrated Healthcare Unit Paramedic" is defined as a registered paramedic who is a member of and providing services for Alberta Health Services' Mobile Integrated Healthcare Unit