How to Fix 16 Common Rejection Codes - Alberta

We see all kinds of reasons that claims get rejected, so we've decided to start shedding some light on the solutions we've found for some of the more common error codes. If your code isn't here, feel free to post to the comments  for any errors that you'd like to see some more information on what exactly Alberta Health Services wants, and how you can fix the problem!

05A  - Invalid Personal Health Number 

     - review for typos, if it looks clean, is it an out of province card and the claim wasn't set to be OOP?

11 - Locum Business Arrangement 

     - When creating an invoice under the advanced tab there is a field for the locum BA. All locum payments will need to be sent with this data. An easy way to send this information is to setup a default invoice template with these details.

31 - Incomplete Person Data           

     - Usually on Out of Province claims where patient demographic information is missing. Alberta OOP claims require first/last names, birthdate, gender, and full address (address 1, city, province, postal code, country)

37 - Business Arrangement - The BA number is: (a) invalid or blank or (b) restricted to performing specific services or (c) restricted to performing services at a specific facility or (d) not registered with the submitter of the transaction or (e) restricted to patients from a specific area or (f) does not have a relationship with the practitioner identifier submitted.

     -  We typically see this if your BA is not connected to our submitter prefix (CPI) This lets Alberta Health know that we have your permission to be sending your invoices in. If you hold an existing BA with another submitter, that is not an issue, you are able to hold as many BA numbers as needed.

     - Other issues are of course the BA wasn't included on the invoice, or the service code you're submitting doesn't match what was registered on your BA. (ie. surgical codes for a psych skill)

37A PRACTITIONER IDENTIFIER The PRAC ID is blank, invalid or not effective for the date of service.

     - Make sure your prac ID is entered correctly in your provider record. HLINK doesn't accept hyphens, so your prac ID should look like 987654321, you may also be trying to claim a service date outside of when your prac ID was valid

37B SKILL CODE The skill code is invalid or blank.

     -  May be trying to bill for a code outside of your skill type. The skill in your provider record is for fee calculation purposes on our end. Alberta Health pays out based on the skill code attached to your BA. If you need to bill any other skill code you can send it along with your invoice by going to the advanced tab when creating an invoice, and add to the skill code field. Alberta Health has a specific format they follow, so make sure to click the relevant skill code from the search list when you type into this field.

39 DATE OF SERVICE The date of service is: (a) invalid or blank or (b) more than one year from date of birth (newborn) or (c) in conflict with the explicit modifier indicated.

     - This one is pretty self explanatory.  As an example, if a weekend premium modifier is used the service date needs to be on a weekend, or if billing a fee modifier such as L40 on a patient outside of the corrected age range.

39DA FACILITY NUMBER The facility number is invalid or blank.

     - A Facility number must be sent along with the invoice unless the location is marked as HOME or OTHER. Your default/most common facility should be added to your provider record along with the functional centre you work at within the facility.  A couple of handy tricks to handle multiple locations would be to create multiple provider records, one for each location. The benefit of this is it makes your reporting by location a snap. Just filter by provider record and get accurate invoice and revenue reporting by location. Another method if the extra layer of reporting isn't as important would be to set up invoice templates with the update facility numbers. When you select the invoice template from the dropdown, it will overwrite all of your default details.

39DB FUNCTIONAL CENTER CODE The functional center: (a) is blank or invalid or (b) is not appropriate for the service submitted or (c) does not exist for the facility submitted.

     - This is a really common rejection reason for doctors who are new to their own billing, as commonly they're not even sure what their functional centre is. Hospital in-patient will commonly be MED, surgical will be SURG, surgical suite is SGSU, etc. If there is any doubt about your functional centre it is usually best to contact an administrator at your facility who should be able to point you in the right direction.

39C NUMBER OF CALLS This claim was refused as: (a) the number of calls is invalid or blank or (b) the number of calls is more than the number allowed for this service. If applicable, resubmit the claim with supporting text.

     - If necessary refer to the SOMB, common surgery codes are usually restricted to 2 calls, the first at 100% rate, the second at 50% or 75% - just resubmit with the correct number of calls, or use a time based code or fee modifier that allows for multiple calls.

39EB DIAGNOSTIC CODE The diagnostic code is blank or invalid.

     -  Alberta Health only accepts their version of ICD 9 codes, so code sets such as psychiatry's DSM-IV will not be accepted. For a complete list of acceptable DX codes Alberta Health has documentation . Or consult your ClinicAid DX codes field; if you enter a code and it doesn't show up in our list, Alberta Health doesn't accept it.

39FA AMOUNT CLAIMED/USE CLAIMED AMOUNT INDICATOR Your claim was refused as: (a) the amount claimed is blank. Claims for unlisted procedures (HSCs in the 99.09 series) require a claimed amount and a "Y" in the claimed amount indicator field or (b) the amount claimed is blank or invalid and the claimed amount indicator is "Y" or (c) the amount claimed is completed, but the claimed amount indicator is blank or invalid.

     - Claimed amount indicator must be used. You can find it through the 'extra fields' icon to the left of the 'add' button when creating invoices. Enter your claimed amount, and make sure the claimed amount indicator is checked.

50AB SECOND OR SUBSEQUENT PROCEDURE Payment for the procedure was reduced to 50% as this service was performed as a second or subsequent procedure through the same incision.

     - If another surgical procedure was done on the same day Alberta Health will only pay out the full amount for one of them at their own discretion, if you feel this was done in error you can always reassess and provide some explanation text  in the provided field.

63 CLAIM IN PROCESS Your claim is being held as: (a) it requires manual assessment or (b) the supporting information must be reviewed. DO NOT SUBMIT A NEW CLAIM, as notification of payment or refusal will appear on a future Statement of Assessment.

     - Just hang on until next week's remittance. Held payments are usually paid out pretty quick.  As the code says, they just need to manually review. Generally any payment that is sent with supplemental text claim notes will be held for review.

63A SCHEDULE OF BENEFITS Payment for your claim was reduced or refused in accordance with the applicable benefits schedule. To view the benefits schedules, go to the Alberta Health and Wellness website at www.health.alberta.ca.

     - This is a difficult one, usually there isn't a direct way to diagnose this issue from looking at the data in your ClinicAid account. The ranges for this particular code can be quite broad from the service code isn't valid for your facility to the complex care code used is incorrect. The best solution for researching these particular issues is calling the Alberta Claims/Assessment Office at 1.780.422.1600

67A PREVIOUS PAYMENT Payment for this service was refused as: (a) the claim was previously paid or (b) the claim was applied at "0" on a previous Statement of Assessment or (c) the claim was previously paid under a different HSC for the same service under another benefits schedule. NOTE: Requests for a reassessment of applied at "0" claims must be submitted with the original claim number and the appropriate action code of "C" (Change), "D" (Delete) or "R" (Reassess). Hospital reciprocal claims are an exception and must be resubmitted as described in the Alberta Health and Wellness Hospital Reciprocal Claim Submission Guide.

     - The best way to research this issue will be to go to your 'manage invoices' and 'all' tabs. Enter the patient name in the patient name search filter field, and click 'go'. From here you can check to see if you may have accidentally duplicated a payment by reviewing the service date and service codes billed. If you have seen a patient twice on the same day for the same service code, you will just need to edit the duplicated invoice to update the encounter field to 2 to signify to AHS that this isn't a duplicate, rather the second encounter with this patient. No need to worry about resending with the "C" code, if you've edited the rejection in ClinicAid and resent, we update the code automatically. If you want to Reassess, you just need to click on the view/eye icon and there will be a reassess button at the top of the invoice to send back to Alberta Health

Too long, didn't read! Periodically as we get requests we'll be updating this list or posting to a new one, so stay tuned for more info!