There are times when a procedure has an added level of complexity or takes an extremely long time due to its complexity. For these types of cases, physicians can request additional compensation over and above the rate that is listed in the Schedule of Medical Benefits through the Extraordinary Medical Services Assessment Fund.
According to Governing Rules 2.6 benefits may be claimed in excess of those listed in the SOMB for services involving unusual complications or care. Requests for increased compensation require additional documentation, either an operative report or other detailed description of the care to support the claim.
To submit a claim for additional compensation:
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- First, consider if the claim is reasonable: Did the procedure have unusual complications that contributed to the increased level of time or intensity? Did the procedure require significantly more time than the average for this procedure?
- Consider how much additional compensation you will request.
- Prepare a letter that summarizes your request and rationale as to why this claim should be considered for additional compensation.
- Locate the operative report and prepare for faxing.
- Enter the claim information as usual using the Health Service Code and patient demographic information. Check the EMSAF indicator box of the claim (you may have to contact your software provider to find out where this is located in your program). You will also enter text on the claim that states you are requesting additional compensation for the claim and state the amount you are requesting. If you do not check the EMSAF indicator box your claim will not enter into the queue for additional compensation.
- Once you have submitted the claim your software will provide you with a claim number. Record the claim number on the top right hand corner of the letter and all pages of the operative report. Fax the letter and the operative report to 780.422.3552.
- The claim will appear on the next Statement of Assessment from Alberta Health as paid at the listed rate. Do not be alarmed, the additional compensation may be paid after the Additional Compensation Committee reviews the claim. Typically this committee meets every quarter and claims are paid shortly thereafter. These claims are processed manually so there is a lag-time between submission and payment of the additional compensation. As a note, not all claims that are submitted for additional compensation are paid as requested.
For more advice from AMA staff on any billing issues, please email AMA billing staff or visit the Billing help page.