AR 81/2006 CLAIMS FOR BENEFITS REGULATION (Consolidated up to 15/2016)
Alberta Regulation 81/2006
Alberta Health Care Insurance Act
CLAIMS FOR BENEFITS REGULATION
Table of Contents
1 Definitions
2 Application of other regulations
3 To whom benefits are payable 4 Payment to practitioner
5 Form of claim
6 Adjustment of claim permitted
7 Limitation period for claims
8 Extended illness outside Alberta
9 Disruption in hospital services
10 Repeals
Definitions
1 In this Regulation,
(a) “Act” means the Alberta Health Care Insurance Act;
(b) “carrier” means a carrier as defined in section 26 of the Act;
(c) “dependant” means a dependant as defined in the Alberta Health Care Insurance Regulation;
(d) “insurer” means an insurer as defined in section 26 of the Act;
(e) “self‑insurance plan” means a self‑insurance plan as defined in section 26 of the Act.
Application of other regulations
2 The payment of benefits for health services is subject to this Regulation and to any other applicable regulation under the Act relating to those benefits.
To whom benefits are payable
3(1) Subject to subsection (4), the Minister may, in respect of a health service provided in Alberta to a resident or to a resident’s dependant who is a resident, pay benefits to
(a) the resident,
(b) the practitioner who provided the health service, or
(c) a third party who at the request of the Minister
(i) provides evidence satisfactory to the Minister that he or she paid for the health service provided, or
(ii) has entered into an agreement with the Minister for the reimbursement of benefits paid by the third party.
(2) Subject to subsection (4), the Minister may, in respect of a health service provided outside Alberta in another province or a territory of Canada to a resident or to a resident’s dependant who is a resident, pay benefits to
(a) the resident,
(b) the resident’s insurer, if the insurer
(i) provides evidence satisfactory to the Minister that the insurer paid for the health service provided, or
(ii) has entered into an agreement with the Minister for the reimbursement of benefits paid by the insurer,
(c) the practitioner who provided the health service,
(d) a health care facility,
(e) the government of a province or territory in Canada, as the case may be, or
(f) a third party who is not an insurer and who at the request of the Minister
(i) provides evidence satisfactory to the Minister that the third party paid for the health service provided, or
(ii) has entered into an agreement with the Minister for the reimbursement of benefits paid by the third party.
(3) Subject to subsection (4), the Minister may, in respect of a health service provided outside Canada to a resident or to a resident’s dependant who is a resident, pay benefits to
(a) the resident,
(b) the resident’s insurer, if the insurer
(i) provides evidence satisfactory to the Minister that the insurer paid for the health service provided, or
(ii) has entered into an agreement with the Minister for the reimbursement of benefits paid by the insurer,
(c) the practitioner who provided the health service,
(d) a health care facility, or
(e) a third party who is not an insurer and who at the request of the Minister
(i) provides evidence satisfactory to the Minister that the third party paid for the health service provided, or
(ii) has entered into an agreement with the Minister for the reimbursement of benefits paid by the third party.
(4) No benefits may be paid to a third party under subsections (1) to (3) without first having obtained the written consent of the resident.
(5) The Minister may, in accordance with and subject to the conditions contained in an agreement referred to in section 17 of the Alberta Health Care Insurance Regulation, pay benefits in the amounts and to the persons authorized by that agreement.
Payment to practitioner
4(1) In this section, “clinic” means a group of practitioners who practise their profession together.
(2) A practitioner may assign the benefits to which the practitioner is entitled to
(a) a clinic of which the practitioner is a member,
(b) an organization that employs or has entered into a service agreement or arrangement with the practitioner, or
(c) another practitioner.
(3) Every practitioner who submits a claim for benefits for payment by the Minister is responsible for ensuring the accuracy of the information and is liable for inaccurate information shown on the claim for benefits.
Form of claim
5(1) A claim for benefits must include the information required by the Minister and must be submitted in a manner determined by the Minister.
(2) When a person has submitted a claim for benefits, the person must provide to the Minister, in a manner determined by the Minister, any further information respecting the claim that the Minister requires.
Adjustment of claim permitted
6 If a person has received payment from the Minister with respect to a claim or claims for benefits and subsequently requests adjustment in the amount paid because of an error, the Minister may make the adjustment.
Limitation period for claims
7(1) Unless the Minister considers that extenuating circumstances exist, a claim for benefits for health services provided to a resident is not payable
(a) if the Minister receives the claim from a practitioner in Alberta more than 180 days after the date the health service was provided or the resident was discharged from hospital, or
(b) if the Minister receives the claim from a resident, a practitioner outside Alberta or a health care facility outside Alberta more than 365 days after the date the service was provided or the resident was discharged from hospital.
(2) Unless the Minister considers that extenuating circumstances exist, a claim for benefits for health services provided in Alberta that is resubmitted for payment is not payable if it is submitted more than 180 days after the last transaction for that claim.
(3) Subsections (1) and (2) do not apply in respect of a claim submitted or resubmitted pursuant to an agreement referred to in section 17 of the Alberta Health Care Insurance Regulation.
Extended illness outside Alberta
8(1) If, in respect of one particular illness or accident, a resident or a resident’s dependant who is a resident obtains health services outside Alberta that extend over a period of more than 3 months from the date the first of those services was received, the resident or a person acting on the resident’s behalf
(a) must, if requested to do so by the Minister, notify the Minister of the reasons why continuation of out‑of‑province care is necessary, and
(b) must provide any details that the Minister requests.
(2) If the Minister receives a claim for benefits with respect to health services referred to in subsection (1), and the resident or a person acting on his or her behalf has complied with subsection (1), the Minister may
(a) continue the payment of benefits,
(b) prescribe the period in which benefits will continue to be paid, or
(c) terminate the payment of benefits.
(3) If a resident fails to comply with a request from the Minister under subsection (1), the Minister may terminate payment of benefits with respect to that illness or accident at any time after 3 months from the date the first of the health services was received.
(4) A resident may assign to an insurer the benefits to which the resident is entitled for a health service provided to the resident or the resident’s dependant outside of Alberta, if the insurer has entered into an agreement with the Minister providing for the assignment.
Disruption in hospital services
9 Notwithstanding section 5 of the Medical Benefits Regulation, if there is a disruption in hospital services arising from a labour dispute and the Minister is of the opinion that it is necessary to transfer a resident outside Canada to receive services that are insured services in Alberta, the Minister may pay benefits in respect of those services in the amount charged by the physician or organization rendering the service.
Repeals
10 The Claims for Benefits Regulation (AR 204/81) and the Payment for Out‑of‑Province Medical Claims Regulation (AR 282/85) are repealed.
11 Repealed AR 15/2016 s1.
