Claims Processing Solution (CPS)

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IMPORTANT INFORMATION

+ Reinstatement of the 6-Month Deadline Requirement for Claims Submission – Aug. 24, 2017

On August 24, 2017, Manitoba Health, Seniors and Active Living (MHSAL) notified all providers that the statutory requirement for submission of claims within 6 months of the date of service, will be reinstated effective January 1, 2018.

This means, for example, that a claim with a service date of July 1, 2017 must be received by MHSAL in an acceptable format no later than January 1, 2018.

Please note that the reinstatement of the 6 month claims submission deadline also applies to the date of service on corrected (“resubmitted”) claims, which were previously rejected by CPS.

The temporary extension of 1 year will remain in effect until January 1, 2018. It is important that you submit any older claims within 1 year of the date of service, as soon as possible (before January 1, 2018).

If you have specific questions or concerns with respect to your claims submissions or require additional information, please do not hesitate to contact the Claims Unit – Claims Enquiry at 204-786-7355. Additional information regarding claims submission requirements can also be found in the Manitoba Physician’s Manual on page CLMST-1.

– posted Sept. 13, 2017

+ CCM and CDM Billing Information - Updated August 1, 2017

Effective April 1, 2017, five new Comprehensive Care Management (CCM) benefit codes (tariffs) will be added to the Manitoba Physician’s Manual. The complete tariff descriptions can be found here: www.gov.mb.ca/health/claims/docs/ccmtariff_2017.pdf.

EOB 4Y - The Passive Enrolment Solution for CCM Claims

An issue was uncovered that impacted claims from clinics who passively enrolled their patients, and had their first Primary Care Data Extract (PCDE) bulk upload to the Home Clinic Portal after April 1, 2017. The Home Clinic Portal was designed to set the passive enrolment start date equal to the date the extract was processed.

Example: If a clinic submitted a CCM claim with a service date of April 1, 2017, but didn't submit their bulk enrolment until April 10, 2017, the CCM claim would have rejected with the following explanation of benefit (EOB) code:

EOB 4Y - This service was rejected as the date of service is outside of the effective date of the enrolment record.

A solution has been implemented for this passive enrolment issue, and eligible claims previously rejected solely with EOB 4Y will be re-processed, starting with the August 15, 2017 remittance advice statement. To ensure all eligible claims are processed, we will monitor and re-process these particular claims over the next few remittance advice statements.

It is important to note that incoming CCM claims (for passively enrolled patients) that have dates of service prior to the date the PCDE bulk upload was made to the Home Clinic Portal, may still reject with EOB 4Y.

On a go forward basis, if a claim is submitted for a passively enrolled patient, and the claim is subsequently rejected with EOB 4Y because of the scenario described above, please wait 2 remittance advice statements for us to re-process eligible claims.

If your previously rejected claim(s) with EOB 4Y has not been re-processed for payment within 2 remittance advice statements, an enrolment by another physician for that patient may have occurred. To inquire further, please contact the Home Clinic team at 204-926-6010, or 1-866-926-6010, or homeclinic@manitoba-ehealth.ca with your enrolment question. You can also visit their website at www.manitoba-ehealth.ca/emr-hclinic.html. They will be able to assist you with your enrolment questions.

Any other CCM claim rejections where the physician believes they have met all the criteria of the CCM benefit(s), should submit a query with explanation and supporting documentation (if available), to the Claims Unit for review.

Important information and billing tips for Comprehensive Care Management (CCM) tariffs:
  • The requirements for billing the new CCM tariffs add an increased level of complexity for claims adjudication, including a reliance on patient enrolment information and potential interactions with existing Chronic Disease Management (CDM) tariffs.
  • In an effort to ensure that MHSAL’s claims processing system is applying the adjudication rules as expected, Manitoba Health, Seniors and Active Living (MHSAL) will initially pend all claims with a CDM or CCM tariff billed, for a short period of time.  Your patience is appreciated during the final implementation stage of these new CCM tariffs.
  • To avoid other tariffs from pending with your CCM or CDM tariffs, MHSAL recommends that you submit CDM or CCM tariffs on their own claim, separate from any other tariffs (e.g. visit tariff) with the same date of service. 
  • There is a systematic one-day delay in the transfer of patient enrolment information to the Claims Processing System.  To prevent an automatic claim rejection, please wait at least one full business day after your enrolment information has been submitted before submitting your CCM claim.
  • CCM tariffs 8454 and 8455 should be claimed using ICD V700.
  • For CCM tariffs 8456, 8457, 8458, an ICD code specific to an eligible chronic condition must be submitted on the claim.
  • We encourage physicians, billing staff and vendors interested in learning more about the requirements for billing these benefits to access MHSAL’s CCM Tariff FAQ and the Manitoba eHealth Home Clinic site.
  • CCM Tariff FAQ: http://www.gov.mb.ca/health/primarycare/providers/clinic/ccmtariff.html
  • Manitoba eHealth Home Clinic Site: http://www.manitoba-ehealth.ca/emr-hclinic.html
  • Registering with MHSAL as a Home Clinic is a prerequisite to patient enrolment and, for clinics, to submission of claims for the Comprehensive Care Management tariffs (effective April 1, 2017). For further information or assistance with patient enrolment, please contact 204-926-6010, 1-866-926-6010 or homeclinic@manitoba-ehealth.ca.

  • Information regarding specific claims is available by calling the Claims Unit staff at CLAIMS ENQUIRY 204-786-7355.

- posted March 23, 2017

+ UPDATE - All FOB Holders - Expected DELAY to RSA Token Replacement (EPICS/Weblink) - April 2017

A notice was sent to all FOB holders in March 2017 regarding the RSA token replacement for EPiCS/Weblink.  Unfortunately the replacement token (SafeNet) deployment date has been delayed.  All current RSA FOB holders will continue to have uninterrupted service, and will have the ability to submit claims using your existing RSA token (FOB) without change.  An email will be sent to all FOB holders in the near future with the new SafeNet token deployment date.

- posted March 31, 2017

+ Attention All FOB Holders - RSA Token Replacement (for EPiCS/Weblink) - March 1, 2017

This notice is to make you aware that beginning in March 2017, all FOB Holders for EPiCS/WebLink will receive via regular Canada Post Mail, a new FOB.  This will replace the RSA token that they currently have for logon to Manitoba Health, Seniors and Active Living (MHSAL) for Uploads and Downloads.  Upon receipt of the package, please follow the instructions included with the new FOB in order to access the upload download screen.  The new FOB is referred to as SafeNet instead of RSA.  The screen may look slightly different as well but all of the logon details will be the same and the link to connect to MHSAL will be the same.  Please ensure you give your full attention to that communication to enjoy uninterrupted connectivity with us for submission uploads and remittance downloads.

+ Billing Bulletins - November 10, 2016

The Billing Bulletin provides billing guidance when submitting claims to Manitoba Health, Seniors and Active Living (MHSAL) for tariffs regarding interventional cardiology found in the Cardiovascular System section of the Manitoba Physician’s Manual (the Physician’s Manual).

The Physician’s Manual is the authoritative reference when submitting medical claims to MHSAL. The Billing Bulletin reflects the Surgical Rules of Application and Notes set out in the Physician’s Manual. For ease of reference the tariffs have been grouped into categories.

Billing Bulletins

+ Important Updates to the Primary Caregiver Tax Credit - October 21, 2016

The Primary Caregiver Tax Credit is an annual refundable personal income tax credit that can be claimed by any Manitoban who is providing ongoing voluntary care to a family member, a friend or a neighbour in Manitoba. The PCGTC rate can be found at:  www.gov.mb.ca/finance/tao/caregiver.html

The care recipient must be assessed by the Regional Health Authority (RHA), Department of Families or a health care professional (e.g. nurse, social worker, occupational therapist, physiotherapist or physician), as requiring the equivalent of Home Care Level of Care 2, 3 or 4.

A revised Level of Care Equivalency Guide form has been created.  

The revised form:

  • better reflects what ‘Level 2 care’ means with updated criteria; and
  • requires the answer of ‘yes’ for personal care assistance to be considered valid.

As of May 1, 2016 the revised Level of Care Equivalency Guide must be used and can be found at:  www.gov.mb.ca/finance/tao/caregiver.html

Please destroy any old forms that may be available in your offices.
+ Start or Start & Stop Time - September 14, 2015

START or START & STOP TIME

The use of the Start and Stop Time fields without unnecessary remarks will expedite claims adjudication.

24-Hour Format. “START” or “START & STOP” times must be entered in a 24-hour format, for example 11:30 p.m. is entered as 23:30.  24:00 and 00:01 are appropriate entries; however 24:01 or 00:00 are not valid start or stop times.

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+ Bilateral / Incision Indicator Field - April 22, 2015

Valid values for this field on the new CPS are as follows:

    • B–Bilateral
    • S–Same incision
    • D–Different incision
    • Blank–If not applicable to the line item

The Bilateral/Incision Indicator field must be blank when not applicable.

The Bilateral/Incision Indicator field should be used when submitting claims for procedures performed bilaterally (at the same sitting) and to indicate when multiple procedures are performed through the same or separate incisions.  The use of this field without adding unnecessary remarks will expedite claims adjudication.  ...MORE

+ Chronic Disease Management (CDM) - April 22, 2015

The options for submitting your patient care treatment forms for general practitioners in fulfilling the requirements for billing benefit codes (tariffs) 8431, 8433, 8434 and 8435.

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+ PHIA On Line Training Sessions - December 16, 2014

The Personal Health Information Act (PHIA) requires all health information trustees, including health care facilities (ex: medical clinics and laboratories), health services agencies and privately practicing licensed, registered or designated health professionals to be familiar with PHIA and to develop policies and procedures as required by the Act.

To assist trustees in complying with the many requirements of this law, Manitoba Health, Seniors and Active Living (MHSAL) has developed a PHIA Online Training Program. This program provides a comprehensive review of The Personal Health Information Act (PHIA) and offers the following three versions free of charge...

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+ Six (6) month deadline for claims submissions, including re-submissions - November 5, 2014

What will happen to claims submitted past the 6-month time frame?

Manitoba Health, Seniors and Active Living (MHSAL) provides coverage for insured medical services in accordance with The Health Services Insurance Act and its regulations.  Section 4(2) of the Medical Services Insurance Regulation 49/93 states:

Payment to doctor
4(2)  A medical practitioner who provides an insured medical service to an insured person, and who has not made an election under subsection 91(1) of the Act, shall submit to the minister:

(a) a claim for the service within six months from the date on which the service was provided in the form and manner required by the minister; and

(b) such further information respecting the service in a form and manner as may be required by the minister.

Claims (including re-submitted claims) received by MHSAL more than 6 months after the service date will be rejected with Explanation of Benefits (EOB) code C2 This claim was refused as this service was not submitted within 6 months from the date on which the service was rendered. ...MORE
+ ICD-9-CM Codes

The requirement of a valid ICD-9 CM code affects MEDICAL (Physician and RN(EP)), DENTAL (Oral Surgery) and Optometric claims only. 

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+ What is a Remittance Advice? - August 29, 2014

A Remittance Advice is the electronic information file that MHSAL provides each pay period to assist you with reconciling your claims in your practice management systems.  The remittance file is available for download from MHSAL beginning on the 3rd business day after the electronic claim cut-off date until the next cut-off.  Each remittance file must be downloaded by your billing staff. 

The decision regarding the information you wish to extract from the remittance file should be made by you and your billing software vendor or service bureau.   The list below shows the type of information that MHSAL reports back to providers on the Remittance Advice file each pay period.  If there are items in the list below that you would like to see on your reports, please contact your vendor to discuss.  ...MORE

+ Personal Health Identification Number (PHIN) - August 29, 2014

What patient demographic information is required in CPS?

Every claim should have the following six (6) fields correctly completed for patient demographics:

  •  PHIN
  • Registration Number
  • Birth Date
  • Gender
  • Given Name (patient)
  • Surname (patient)

The PHIN is a mandatory field on all claims.  If the PHIN is not correctly entered on the claim, it will be rejected.  ...MORE

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Questions?

If you have questions, please contact our Claims Unit General Line at 204-786-7355.