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
11 Expiry
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.
Expiry
11 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.