(no amdt)

ALBERTA REGULATION 86/2006

Alberta Health Care Insurance Act

ORAL AND MAXILLOFACIAL SURGERY BENEFITS REGULATION

Table of Contents

                1       Definitions

                2       Eligibility

                3       Benefits for services in Alberta

                4       Benefits for services in Canada

                5       Benefits for services outside Canada

                6       Increased benefit

                7       Included in amount of benefits

                8       Repeal

                9       Expiry

List of Oral and Maxillofacial Surgery Services

Definitions

1   In this Regulation,

                                 (a)    “Act” means the Alberta Health Care Insurance Act;

                                 (b)    “oral and maxillofacial surgery services” means the services in the List of Oral and Maxillofacial Surgery Services in this Regulation;

                                 (c)    “Schedule of Oral and Maxillofacial Surgery Benefits” means the Schedule of Oral and Maxillofacial Surgery Benefits prepared and published by the Department of Health and Wellness and approved by the Minister.

Eligibility

2(1)  Benefits are payable in accordance with the regulations under the Act for oral and maxillofacial surgery services provided to a resident of Alberta by a dentist.

(2)  Notwithstanding subsection (1), benefits are not payable for oral and maxillofacial surgery services if a declaration under section 25 of the Health Insurance Premiums Act is in effect in respect of the person who receives the services.

Benefits for services in Alberta

3(1)  The benefits payable for oral and maxillofacial surgery services provided to a resident of Alberta in Alberta and the descriptions of those services are set out in the Schedule of Oral and Maxillofacial Surgery Benefits.

(2)  Notwithstanding subsection (1), the benefits payable for oral and maxillofacial surgery services provided to a resident of Alberta in Alberta are limited to the lesser of

                                 (a)    the amount claimed, and

                                 (b)    the rates established in the Schedule of Oral and Maxillofacial Surgery Benefits.

Benefits for services in Canada

4(1)  The benefits payable for oral and maxillofacial surgery services provided to a resident of Alberta in another province or territory of Canada that are insured services in Alberta are determined as follows:

                                 (a)    if the services are insured services under the legislation in that province or territory, the benefits are payable according to the rules established for payment of benefits in that province or territory and the benefits payable are limited to the lesser of

                                           (i)    the amount claimed, and

                                          (ii)    the rates established by that province or territory;

                                 (b)    if the services are not insured services under the legislation in that province or territory, the benefits are payable according to the Act and the regulations under the Act and the benefits payable are limited to the lesser of

                                           (i)    the amount claimed, and

                                          (ii)    the rates established in the Schedule of Oral and Maxillofacial Surgery Benefits.

(2)  No benefits are payable for oral and maxillofacial surgery services provided to a resident of Alberta in another province or territory of Canada if the services provided are not insured services in Alberta.

Benefits for services outside Canada

5(1)  The benefits payable for oral and maxillofacial surgery services provided to a resident of Alberta outside Canada that are insured services in Alberta are limited to the lesser of

                                 (a)    the amount claimed, and

                                 (b)    the rates established in the Schedule of Oral and Maxillofacial Surgery Benefits.

(2)  No benefits are payable for oral and maxillofacial surgery services provided to a resident of Alberta outside Canada if the services provided are not insured services in Alberta.

Increased benefit

6(1)  Notwithstanding sections 3 and 4, a benefit that is higher than the rate set out in the Schedule of Oral and Maxillofacial Surgery Benefits may be payable for oral and maxillofacial surgery services provided to a resident of Alberta in Canada if unusual complications occur or unusual care is required.

(2)  A request for an increased benefit must be accompanied by supporting evidence satisfactory to the Minister.

Included in amount of benefits

7   The benefits payable for oral and maxillofacial surgery services provided to a resident of Alberta by a dentist include an amount for the following:

                                 (a)    performing the oral or maxillofacial surgery service;

                                 (b)    administration;

                                 (c)    recording of information regarding the services provided unless if the recording of the information is for the purposes of a third party;

                                 (d)    completing and submitting claims;

                                 (e)    discussion or correspondence with a referring health care professional regarding treatment or a service to be provided to a patient directly related to managing the patient’s care, unless otherwise provided in this Regulation or the Alberta Health Care Insurance Regulation.

Repeal

8   The Oral and Maxillofacial Surgery Benefits Regulation (AR 123/95) is repealed.

Expiry

9   For the purpose of ensuring that this Regulation is reviewed for ongoing relevancy and necessity, with the option that it may be repassed in its present or an amended form following a review, this Regulation expires on February 15, 2016.

List of Oral and Maxillofacial
Surgery Services   

                                 (a)    non‑operative endoscopy of respiratory tract;

                                 (b)    other non‑operative endoscopy;

                                 (c)    diagnostic interview and evaluation or consultation;

                                 (d)    injection or infusion of other therapeutic or prophylactic substance;

                                 (e)    other injection or infusion of other therapeutic or prophylactic substance;

                                  (f)    other miscellaneous diagnostic and therapeutic procedures;

                                 (g)    cranioplasty;

                                 (h)    incision, division and excision of cranial and peripheral nerves;

                                  (i)    destruction of cranial and peripheral nerves;

                                  (j)    suture of cranial and peripheral nerves;

                                 (k)    freeing of adhesions and decompression of cranial and peripheral nerves;

                                  (l)    transposition of cranial and peripheral nerves;

                                (m)    injection into peripheral nerve;

                                 (n)    control of epistaxis;

                                 (o)    submucous resection of nasal septum;

                                 (p)    reduction of nasal fracture;

                                 (q)    repair and plastic operations on the nose;

                                  (r)    intranasal antrotomy;

                                 (s)    repair and plastic operation of nasal sinus;

                                  (t)    excision of dental lesion of jaw;

                                 (u)    other orthodontic operations;

                                 (v)    other dental operations;

                                (w)    partial glossectomy;

                                 (x)    complete glossectomy;

                                 (y)    repair and plastic operations on tongue;

                                 (z)    invasive diagnostic procedures on tongue;

                               (aa)    other operations on tongue;

                              (bb)    incision of salivary gland or duct;

                               (cc)    excision of lesion of salivary gland;

                              (dd)    sialoadenectomy;

                               (ee)    other operations on salivary gland or duct;

                                (ff)    drainage of face or floor of mouth;

                              (gg)    incision of palate;

                              (hh)    excision of lesion or tissue of palate;

                                 (ii)    plastic repair of mouth (internal);

                                 (jj)    palatoplasty;

                               (kk)    invasive diagnostic procedures on oral cavity;

                                 (ll)    other operations on mouth and face;

                             (mm)    plastic operation on pharynx;

                              (nn)    temporary tracheostomy;

                              (oo)    incision of chest wall and pleura;

                              (pp)    other operations on vessels;

                              (qq)    closed reduction of facial fractures;

                                (rr)    open reduction of facial fractures;

                               (ss)    incision of facial bone without division;

                                (tt)    partial ostectomy of facial bone, except mandible;

                              (uu)    temporomandibular arthroplasty;

                              (vv)    other facial bone repair and osteoplasty;

                             (ww)    invasive diagnostic procedures on facial bones;

                                (xx)    other operations on facial bones and joints;

                              (yy)    sequestrectomy;

                                (zz)    synovectomy;

                             (aaa)    other operations on joints;

                            (bbb)    incision of muscle, tendon, fascia and bursa;

                             (ccc)    excision of skin and subcutaneous tissue;

                            (ddd)    relaxation of scar or contracture of skin;

                             (eee)    flap or pedicle graft;

                               (fff)    plastic operations on lip and external mouth;

                            (ggg)    ill-defined operations.