Rejected claims – explanatory code 21 (WCB)

Claims that are reversed by Alberta Health and the explanatory code is 21 (shown on your Statement of Assessment) need to be submitted to WCB for payment.

This claim was refused or updated as:
(a) claim is responsibility of Workers Compensation Board (WCB), or
(b) claim has been changed to HSC 03.01J, as it is for an unrelated condition in association with a WCB claim for the same date of service.

In March 2014, Alberta Health sent out Bulletin #Gen 87 advising physicians that they were matching WCB files to AH files to look for claims that should have been WCB and then recovering those claims and advising physicians to send the claims to WCB. AH runs this file-matching exercise rather infrequently and may result in rejections/recoveries for claims that are over three years old.

The claims that are reversed by AH need to be submitted to WCB for payment. Normally, WCB claims are to be submitted within 180 days of service, however since AH reversed the claims, the 180 day rule will not apply. You will need to send a copy of the refusal from AH to WCB showing they were recently refused when you submit the claims to WCB.

If you are a retired physician and not able to submit these claims electronically, you may write out the billings and fax, with the AH statement, to WCB. No letter of explanation is required. WCB is accepting faxes in this situation. Toll free fax 1.800.661.1993. WCB Claims Contact Centre 1.866.922.9221.

Billing for WCB services is done in accordance with the rules associated with the SOMB, however, there are some differences with WCB related to unbundling. With WCB, if a physician provides any minor procedures, both the visit and the procedure may be billed to WCB. If the service is a major procedure, there are no inclusive care periods, all visits in the pre-procedure and post-procedure are all billable to WCB. Suture removal is also billable to WCB as a visit service. Trays are not paid automatically for services provided in the office; you would need to bill for the tray (MAJT or MINT).

Need more help?

Alberta Medical Association Mission: Advocate for and support Alberta physicians. Strengthen their leadership in the provision of sustainable quality care.