Governing Rules:

• 4.4.8 CLAIMS REQUIRING REFERRING PRACTITIONER NUMBER

  When a claim is submitted for the following HSCs, the referring practitioner field must be completed with a valid referring practitioner number.

  HSCs in the following list marked with an asterisk(*) cannot be self-referred. Self-referred means the physician is providing the diagnostic service and treating the patient.

  HSCs in Section E (Lab and Pathology) and X (Diagnostic Radiology) require a valid referring practitioner number with the following exceptions: HSC X27D does not require a referral and HSC X27F may be self-referred. HSC 03.03D requires a valid referring physician, chiropractor, midwife, podiatrist, dentist, optometrist, physical therapist or nurse practitioner number when it is a visit to a referred patient.

  01.01A	01.01B	01.03	01.04A	01.05A	01.09
  01.12A	01.12B	01.14	01.16A	01.16B	01.16C
  01.22	01.22A	01.22B	01.22C	01.24A	01.24B
  01.24BA	01.24BB	01.32	01.34	02.82A	02.84A
  02.84B

  03.01O*	03.01LJ* 03.01LK* 03.01LL* 03.03D*	03.03F*
  03.03FA*	03.03FV* 03.03FZ* 03.04Q*	03.05B*	03.07A*
  03.07AZ*	03.07B*	03.07C*	03.08A*	03.08AZ* 03.08B*
  03.08BZ*	03.08C*	03.08CV* 03.08F*	03.08H*	03.08K*
  03.08L*	03.08M*

  03.09A*	03.09B*	03.12A	03.16A	03.16B	03.16C
  03.16D	03.19C	03.19D	03.21A	03.22A	03.22B
  03.22C	03.26	03.29A	03.37A	03.37B	03.38A
  03.38B	03.38C	03.38D	03.38E	03.38F	03.38G
  03.38H	03.38K	03.38M	03.38N	03.38P	03.38R
  03.38S	03.38T	03.38X	03.41A	03.41B	03.41C
  03.41D	03.44A	03.45A	03.45B	03.52A	03.52B
  03.52C	03.52D	03.55A	03.55B	03.56A	03.56B

  07.09A	07.09B	08.19A*	08.19AZ* 08.19B*	08.19C*
  08.19AA*	08.19BB* 08.19CC* 08.19CX*	09.01A	09.01B
  09.01C	09.01E	09.02B	09.02E	09.05A	09.05B
  09.06A	09.07C	09.11A	09.11B	09.11C	09.12A
  09.12B	09.13C	09.13D	09.13E	09.13F	09.13G
  09.13H	09.23A	09.23B	09.24B	09.26A	09.26D
  09.41A	09.41B	09.43A	09.43B	09.43C	09.43D
  09.43E	09.46A	09.49A

  10.04	10.08A	10.33B	13.99CC 13.99GA*	14.49A
  14.82	14.85B	14.88A	14.88B	15.94A	16.83A
  16.83B	16.83C	16.89A	16.92B	17.81B	19.81

  22.81	24.89A	24.89B	28.8 A	28.81A	29.0 A
  30.81A	33.22B	37.81	37.82A	37.82B	38.89A
  38.89B	39.21A	39.62A	39.83A

  40.92A	41.29A	41.29B	42.09B	43.81	43.82
  44.3 B	45.81A	45.83	45.84B	45.86A	46.5 A
  46.81A	46.82	46.84A	46.88A	48.92A	48.98A
  48.98B	49.93A	49.95A	49.96A	49.96B	49.98B
  49.98C	49.98D

  50.81A

  50.81B

  50.81C

  50.81D

  50.81E

  50.82A

  50.82B	50.83A	50.84A	50.84B	50.84C	50.87A
  50.87B	50.87C	50.88A	50.89A	50.89B	50.89C
  50.89D	50.89E	50.91B	50.95A	50.95B	50.98A
  52.1 A	52.11A	52.12	52.13	52.85A	53.81A
  53.81B	53.83A	54.89A	54.89B	54.89D	54.89E
  54.89F	57.92A

  60.82C	60.89A	62.12A	62.12B	62.81A	63.86A
  63.96B	64.95A	64.97A	66.19A	66.3 C	66.83
  66.89A	66.89B	66.89C	67.81	67.86	67.87A
  67.89A	68.95	69.83A	69.83B	72.91	72.92A
  74.82A	75.83A	76.89A	78.7 A	79.29E

  80.81	80.83B	80.85A	80.85B	82.12A	82.81A
  82.91A	83.7 A	87.53A	87.53B	87.54A	87.55A
  89.59A	89.59B	89.59G	89.98A	92.70	92.71
  92.72	92.74	92.75	92.76	92.78A	92.78B
  92.78C	92.8 A	92.8 B	95.81A	97.11A	97.11B
  97.81	97.82A	97.83A	97.89A	97.89B	98.12A
  98.12B	98.8 A	98.81A	98.81B	98.89A	98.89B
  98.89C	98.89D	98.89E	98.89F	98.89G	98.89H

  F7

• 6.6.2

  If a procedure designated "+" is performed in a physician's office, both the procedural benefit and the appropriate office visit benefit for that day may be claimed, but if a consultation benefit pursuant to GR 6.6.4 has been claimed, a visit benefit will not be payable for the day on which the procedure is performed.

• 6.6.3

  If a procedure designated "+" is performed in a place other than a physician's office, either a procedural benefit or a visit benefit, but not both, may be claimed for that day.

• 6.6.4

  If a procedure designated "+" and a consultation are provided on the same day, both the procedural benefit and the appropriate consultation benefit are payable.

• 6.7.1

  If a minor procedure (M or M+) is provided with a hospital visit on the same day, only the greater benefit HSC may be claimed.

• 6.8.4

  Where a procedure is performed under general anesthesia, the following applies:

  1. If the procedure is the only procedure performed at that time, a benefit of $134.85 may be claimed.
  2. If another procedure is also performed at the same encounter and the listed benefit payable in respect of it under the Schedule is greater than $134.85 the physician is entitled to receive that listed benefit plus a percentage of the listed benefit for the lesser procedure(s) calculated in accordance with this Schedule. The $134.85 minimum benefit does not apply to the lesser procedures.
  3. If multiple procedures are performed at the same encounter and the listed benefit payable in respect of each of them under the Schedule is less than $134.85, the physician is entitled to receive a benefit of $134.85 in respect of the greater procedure plus a benefit in respect of each of the lesser procedures that is a percentage of the listed benefit and calculated in accordance with this schedule. The $134.85 minimum benefit does not apply to the lesser procedures.
  4. If multiple procedures are performed at the same encounter and only one of them appears under GR 6.8.4 (e), the physician is entitled to receive a benefit of $134.85 in respect of that procedure plus a benefit in respect of the other procedures that is a percentage of the listed benefit and calculated in accordance with this schedule.

  1. GR 6.8.4 applies to the following HSCs:

     01.01A	01.01B	01.03	01.09	01.24A	01.24B
     01.24BA	01.24BB	02.84B	03.22A	03.22B	03.25
     07.29A	07.57A

     10.23	10.25	11.71A	11.81A	12.01	12.21
     12.24	12.31	13.59L	13.59N	13.59O	13.99BB
     14.09A	17.39E	17.81A	19.81

     21.41	21.42	21.69A	21.69C	22.13B	22.13C
     22.5 A	22.81	24.22A	24.5	25.1 A	26.91A
     28.8 A

     30.19A	30.19B	30.9 A	32.01A	32.1	32.21A
     32.23A	32.39A	33.22A	33.22B	33.51A	33.51B
     33.61A	34.0 A	34.1 A	34.89A	35.0 A	37.81
     37.82A	38.0 A	38.89A	39.21A	39.62A	39.83A

     40.5	40.92A	43.95A	45.81A	45.83	45.84A
     46.04B	46.09B	46.09C	46.84A	49.0	49.82B
     49.83A

     50.4 A	50.94D	50.94E	50.94F	50.97A	51.43
     51.53A	52.1 A	53.81B	53.83A	54.92D	58.99F

     60.82C	61.01A	61.29B	61.37A	61.39B	62.81A
     64.95A	66.82A	67.81	67.86	67.96A	68.1
     68.32B	69.13D	69.29A	69.83A	69.83B

     70.1	70.2 A	70.2 B	70.2 H	70.4 F
     70.5 A	72.91	74.82A	76.91A	78.7 A	79.29E

     80.83B	80.85B	81.8	81.96	82.12A	82.12B
     82.12C	82.14D	82.81A	82.91A	83.7 A	87.6
     87.72A	87.82	87.89A	87.89B	87.91	87.92
     88.92	89.59A

     91.01H	91.01J	91.02A	91.03A	91.03B	91.05E
     91.05H	91.06D	91.06E	91.07A	91.08B	91.70A
     91.70B	91.71	91.73A	91.73B	91.77B	91.77C
     91.78A	91.78B	92.70	92.71	92.72	92.74
     92.75	92.76	92.78C	93.91A	93.91B	94.04
     95.02A	95.03	95.81A	95.93	95.96A

     97.81	97.96	98.03A	98.04A	98.12A	98.12B
     98.12C	98.12E	98.12G	98.12H	98.12J	98.12K
     98.12M	98.12N	98.12Q	98.12R	98.22A	98.49A
     98.6 A	98.6 C	98.81A	98.93A	98.93B	98.96A
     98.96B	98.96C	98.96D	98.98B

• 12.7

  An additional benefit per case (modifiers L30AN, L30AT, L30AT2, L44ANE) may be claimed for anesthetic services provided to neonates and infants under 44 weeks of conceptual age. Refer to the Price List for the additional benefit amount.

• 13.3

  Benefits may not be claimed for procedures that do not routinely require the services of a surgical assistant or a 2nd surgeon for a 2nd surgical team, unless supporting information detailing unusual circumstances satisfactory to the Minister is provided. Such procedures include but are not limited to the following list:

  01.01A	01.01B	01.03	01.04A	01.05A	01.09
  01.12B	01.14	01.16B	01.16C	01.22	01.22A
  01.22B	01.22C	01.24A	01.24B	01.24BA	01.24BB
  01.32	01.34	02.84A	02.84B

  03.16A	03.21A	03.22A	03.22B	03.22C	03.26
  03.29A	03.37A	03.38A	03.38B	03.38C	03.38D
  03.38E	03.38F	03.38G	03.38H	03.38K	03.38M
  03.38N	03.38P	03.38Q	03.38R	03.38S	03.38T
  03.38X	03.41A	03.44A	03.45A	03.45B	03.52A
  03.52C	03.55A	03.56A	03.63

  06.35A	06.35B	06.39A	06.39B	07.09A	07.27A
  07.27B	07.29A	07.29B	07.51A	07.51C	07.53A
  07.53B	07.53C	07.53D	07.53E	07.54A	07.56A
  07.57A	07.57B	09.01A	09.01B	09.01C	09.01F
  09.05A	09.06A	09.07C	09.11A	09.12A	09.26A
  09.49A

  10.04	10.08A	10.16A	10.23	10.25	10.33A
  10.33B	10.35	10.55A	10.56A	11.02	11.02A
  11.81A	12.01	12.03	12.05	12.12A	12.12B
  12.13A	12.21	12.23	12.24	12.31	13.4 A
  13.42A	13.53A	13.55A	13.57A	13.59A	13.59B
  13.59C	13.59D	13.72A	13.99A	13.99AA	13.99B
  13.99BB	13.99C	13.99D	14.3 B	14.85B

  15.93A	15.93B	15.93C	15.94A	15.99A	16.2 B
  16.81A	16.83A	16.83B	16.83C	16.89A	16.92A
  17.03A	17.08D	17.08E	17.08K	17.1 A	17.39E
  17.71A	17.81A	17.89A	18.29A	18.29B	19.81

  20.55B

  21.31B

  21.32B

  21.32D

  21.41

  21.42

  21.69A	22.13A	22.13B	22.13C	22.39A	22.5 A
  22.5 B	22.62A	22.71	22.81	23.99A	23.99C
  23.99D	24.22A	24.5	24.89A	24.89B	24.91
  25.1 A	25.29A	25.81A	27.4 A	27.5 A	27.7 A
  27.7 C	27.73A	28.1 A	28.4 A	28.5 A	29.91

  30.19A	30.19B	30.81A	30.9 A	32.01A	32.1
  32.31	32.81	33.01A	33.02A	33.03A	33.21A
  33.22A	33.22B	33.4 C	33.51A	33.51B	33.61A
  33.76A	33.76B	33.76C	33.76D	33.76E	33.76F
  33.76G	34.0 A	34.1 A	34.54A	34.89A	35.0 A
  37.81	37.82A	37.82B	38.0 A	38.89A	38.89B
  39.21A	39.62A	39.83A

  40.0	40.1 A	40.5	40.92A	41.29A	41.29B
  42.09A	42.09B	43.1 B	43.81	43.82	43.95A
  43.96A	43.96B	43.96C	43.96D	43.96E	44.01
  44.22A	45.81A	45.83	45.84A	45.88A

  46.04A	46.04B	46.09B	46.09C	46.84A	46.88A
  46.91	47.02B	47.03A	48.92A	48.98A	48.98B
  49.0	49.61B	49.7 D	49.7 N	49.73A	49.81
  49.82A	49.82B	49.83A	49.84	49.85	49.86
  49.93A	49.95A	49.96A	49.96B	49.98B	49.98C
  49.98D	49.98P	49.98Q	49.98R	49.98S	49.98T
  49.98U

  50.4 A	50.6 B	50.71C	50.75E	50.79A	50.81A
  50.81B	50.81C	50.81D	50.81E	50.82A	50.82B
  50.83A	50.84A	50.84B	50.84C	50.87A	50.87B
  50.87C	50.88A	50.89A	50.89B	50.89C	50.89D
  50.89E	50.91B	50.91D	50.91E	50.93A	50.94D
  50.94E	50.94F	50.95A	50.95B	50.96	50.97A
  50.98A	50.99A	50.99D	51.52A	51.53B	51.59B
  51.65A	51.65B	51.92A	51.92B	51.99A	51.99B

  52.1 A	52.85A	53.42A	53.81A	53.81B	53.83A
  54.21B	54.21C	54.21D	54.21E	54.89A	54.89B
  54.89D	54.89E	54.89F	54.91A	54.92A	54.92B
  54.92C	54.92D	54.92E	55.41A	55.41B	56.34A
  56.93B	57.21A	57.92A	58.99B

  60.82C	60.89A	61.01A	61.03	61.29B	61.37A
  61.39B	62.81A	62.82A	63.96B	63.99A	63.99B
  63.99C	64.95A	64.97A	66.83	66.89B	66.89C
  66.91B	66.91C	66.98A	67.02	67.81	67.83
  67.86	67.87A	67.89A	67.93	67.96A	68.0 A
  68.95	68.99A	68.99B	69.11	69.13D	69.29A
  69.29B	69.29C	69.83A	69.83B	69.94

  70.1	70.2 A	70.2 B	70.2 H	70.4 F	70.4 G
  70.5 A	70.5 B	71.8	71.95	71.96A	72.1 C
  72.91	73.2 A	73.91	74.82A	75.64	75.83A
  76.0	76.1 A	76.89A	76.91A	78.7 A	79.22
  79.23A	79.29C	79.29E

  80.81	80.83B	80.85A	80.85B	81.01D	81.09
  81.8	81.91A	81.96	82.12A	82.12B	82.12C
  82.81A	82.91A	83.09A	83.2 B	83.7 A	84.21D
  85.5 A	87.3	87.53A	87.54A	87.54B	87.55A
  87.6	87.99A	87.99AA	88.02A	88.92	89.98A

  91.00A	91.01A	91.01B	91.01H	91.01J	91.02A
  91.02C	91.02D	91.03A	91.03B	91.04A	91.04B
  91.05A	91.06B	91.06D	91.06E	91.07A	91.08B
  91.08J	91.12A	91.13A	91.72	91.73A	91.73B
  91.77C	91.78B	91.78C

  92.70	92.71	92.72	92.74	92.75	92.76
  92.78A	92.78B	92.78C	93.91A	93.91B	95.03
  95.81A	95.93	95.96A	96.01A	96.01B	96.02A
  96.02B	96.11A	97.81	97.83A	97.89A	97.89B
  97.96

  98.03A	98.03C	98.03E	98.04A	98.04B	98.12A
  98.12B	98.12C	98.12G	98.12J	98.12K	98.12L
  98.12M	98.12N	98.12Q	98.12R	98.12S	98.12T
  98.12U	98.13A	98.22A	98.22B	98.6 A	98.8 A
  98.81A	98.81B	98.89A	98.89B	98.89C	98.89D
  98.89E	98.89F	98.89G	98.92C	98.93A	98.93B
  98.96A	98.96B	98.96C	98.96D	98.98B	98.99AA

• 14.1

  A major tray service benefit may be claimed for the following procedures only when they are performed in a location other than a nursing home, general or auxiliary hospital, AACC, UCC or a facility which has a contract with a regional health authority to provide any of these insured services.

  01.03	01.04A	01.05A	01.24A	01.24B	01.24BA
  01.24BB	01.34	02.84A	02.84B	03.22B	03.25
  07.53B	07.53D	07.53E	07.57A

  12.31

  13.59C

  17.08A

  17.81A

  21.42	21.69A	22.13A	22.13B	22.13C	22.5 A
  22.51A	22.62A	22.71	22.81	25.1 A	25.29A
  25.39D

  32.01A	32.81	33.02A	33.22B	34.0 A	34.1 A
  34.89A	37.82A	38.89A	39.21A	39.62A	39.83A
  39.83A

  40.92A 46.91

  50.4 A

  50.97A

  52.1 A

  52.11A

  52.13

  56.93B

  60.24C	61.01B	61.03	61.29B	61.37A	61.39B
  66.91A

  70.1

  70.5 A

  72.91

  75.64

  79.23A

  79.29E

  82.81A	82.91A	83.7 A	87.3	87.55A	89.37A
  89.37B	89.41A	89.41B	89.42A

  93.39B	93.39C	95.02A	95.09A	95.81A	97.11B
  97.83A	97.89B	98.04A	98.6 A	98.6 B	98.12A
  98.12B	98.12C	98.12H	98.12J	98.12M	98.12N
  98.12Q	98.12R	98.12T	98.14A	98.22A	98.22B
  98.81A	98.96A	98.96B	98.96C	98.96D

• 14.3 MULTIPLE TRAY SERVICE

  If multiple procedures listed under GRs 14.1 and 14.2 are performed during the same encounter in a location other than a nursing home, general or auxiliary hospital, AACC, UCC or a facility which has a contract with a regional health authority to provide any of these insured services, the following applies:

• 14.3.1

  For the same anatomical area (example - 3 moles removed from the face), only one tray may be claimed except when the condition relates to suspected cancer or infection, in which case, if required, additional tray(s) may be claimed at 50%.

• 14.3.2

  For different anatomical areas, the tray for the initial procedure may be claimed at 100% and if required, the tray for each additional procedure may be claimed at 50%.

• 14.3.3

  Benefits for additional trays may not exceed the benefit listed for one major tray.