Schedule of Medical Benefits Change Request form

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Schedule of Medical Benefits Change Request form
REFERENCE
NUMBER
PART A: PHYSICIAN REQUEST
AMA USE ONLY
ALBERTA MEDICAL ASSOCIATION
SCHEDULE OF MEDICAL BENEFITS CHANGE REQUEST FORM
NOTE:
You are asked to TYPE the form and fill in each item and subsection within the item. If the amount of
space is insufficient, please attach the response/information on a separate sheet of paper.
If necessary, use the following abbreviations:
Not applicable - n.a.
Not available - N/A
Unknown – U
1.
Requesting Information
Requester:
Section:
Request Type:
2.
NAME OF PROCEDURE OR SERVICE
NOTE: Use nomenclature, as it would appear in the Schedule of Medical Benefits.
Please do not use eponyms to identify procedures or services.
3.
DESCRIPTION OF SERVICE
NOTE: If service requested is a surgical procedure, provide a detailed description similar to
that of an operative report or attach the actual operative report (deleting patient
identification) if you prefer.
4.
LOCATION OF SERVICE
NOTE: The procedure or service will be provided in the following locations (please X all
that are applicable):
(a) Location:
(b) Facility & Functional Centre:
Active Treatment Hospital (ACT)
Clinic (CLNC)
Day/Night (D/N)
Emergency (EMRG)
Hyperbaric Oxygen Chamber (HBOC)
Neonatal Intensive Care Unit
Level 1 (ICN1)
Level 2 (ICN2)
Level 3 (ICN3)
Obstetrical Intensive Care Unit
Level 1 (ICO1)
Level 2 (ICO2)
Level 3 (ICO3)
Intensive Care Unit
Level 1 (ICU1)
Level 2 (ICU2)
Level 3 (ICU3)
Medical (MED)
Paediatrics Emergency (PEMG)
Surgical (SURG)
Auxiliary Hospital (AUX)
Long Term Care (LTC)
Subacute Care (MED)
Nursing Home (NH)
Office (OFFC)
Non-Hospital Surgical Facility (OFFC)
Surgical Suite (SGSU)
Other:
5.
ANALYSIS OF COMPONENT OF PROCEDURE OR SERVICE
5.1
PROFESSIONAL COMPONENT:
(a)
Pre-service component
What is included in the pre-service component?
NOTE: Please check all that are applicable. As well, please indicate how
many of each pre-service consults or visits are usually provided.
Associated Patient Encounters
Health Service Code
Average Number
Hospital
Office
(b)
Intra-service component
Physician time component (specific to the proposed procedure):
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$ Value
NOTE: Include procedure/service time ONLY as pre-operative and post-operative
visits, if applicable, are included in (a) and (c).
Minimum Time
Maximum Time
Average Time
$ Value
Physician
(c)
Post-service component
What is the average expected care involved after the procedure, which is included in the
total fee?
Associated Patient Encounters
Hospital
Office
Health Service Code
Average Number
$ Value
Total Professional Value (a, b, and c)
(d)
What other practitioners are involved in providing this service or what other costs
to the health care system will occur? Please check all that apply. [See also 9 (e)]
Surgical assistant
Radiology services
ICU post-operative care
Other inter- or intra-speciality consultations
Others (please describe)
5.2
TECHNICAL COMPONENT: (Encompasses technician and overhead)
(a) Technician1 time component
Minimum Time
Technician
Technical Discipline
Hourly Rate
Maximum Time
Average Time
$ Value
(b) Overhead component
$ Value
(i) Equipment
Amortization of cost or leasing costs of any special equipment needed to carry out
procedure (indicate costs incurred by physician only and basis of amortization, as
well as amortization period, percentage per year, tests per year):
NOTE: Details of Equipment calculation must be attached
(ii) Expendable costs (specific to the proposal procedure):
(Please provide details of the costs, per test.)
NOTE: Details of Expendable Costs calculation must be attached
1Complete
only if technical personnel are involved in the service and the fee/benefit includes a component
to cover their service, e.g., a lab test, measurement of system function.
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(iii) Other costs2 (overall cost divided by all services provided in the
facility/office):
General Cost Breakdown – Per Service
Staff:
Supplies:
Indirect Overhead Costs (Office Space) – Per Service
Lease:
Tax:
Utilities
Insurance
Other:3
Total Technical Fee (a, b(i), (ii), (iii)
(c)
6.
FREQUENCY OF PROCEDURE OR SERVICE
(a) What is the expected utilization of the new procedure or service, by ALL practitioners in the
province of Alberta in the next 36 months? (Be as specific as possible)
i)
First twelve months
ii)
Second twelve months
iii)
Third twelve months
(b) How are the frequency estimates in (a) calculated?
(c) What other section(s), if any, will provide this fee item?
NOTE: Please indicate the percentage of services that will be provided by the involved
section(s).
7.
CATEGORY CODE
All items in the Schedule of Medical Benefits are assigned a category code (see General Rules
2.5.1 and 6.8.1.). Please indicate which of the following category codes is applicable.
NOTE: The assigned category code should be relative to similar items in the schedule.
Category
2Cost
Pre-operative
Post-operative
not covered in specific procedure but common to all procedures, e.g., receptionist, billing clerk.
3Please
provide details of all other costs that were included.
Page 4
C
R
V
T
M
M+
1
3
4
6
14
15
8.
0 - Days
0 - Days
0 - Days
0 - Days
0 - Days
0 – Days
0 - Days
7 - Days
7 - Days
14 - Days
30 - Days
0 - Days
0 - Days
0 - Days
0 - Days
0 - Days
0 – Days
0 - Days
14 - Days
7 - Days
14 - Days
14 - Days
14 - Days
7 - Days
INTERPROVINCIAL COMPARISON OF THE PROCEDURE OR SERVICE
Is a comparable benefit code provided in other province(s)? (Please detail the elements included
in the listed benefits):
Province
Fee Code Number, Description and Benefit Rate
9.
RELATIONSHIP BETWEEN THE PROPOSED PROCEDURE OR SERVICE AND
TERMS CURRENTLY LISTED IN THE SCHEDULE OF MEDICAL BENEFITS
(a)
Is the proposed procedure/service currently paid for by Alberta Health?
Yes/No
$ Amount
Assessment Advisory4
By Assessment4
Other4
(b)
Indicate the current benefit code(s) and benefit rate(s) for which payment has been made
for the proposed item. If the proposed item involves two procedures, for example one
paid at 100% and the other paid at 75% of the listed rate, indicate both fee codes and the
payment rates of 100% and 75% respectively,
(c)
Indicate the current benefit code(s) that may be replaced by the new procedure or service.
(d)
Indicate the portion (percentage of services detailed in (c) above) of services provided
under the existing benefit code(s) that may be replaced by the new procedure or service.
(e)
Indicate other existing benefit code(s) that will be provided in conjunction with
the proposed service. [See also 5.1 (d)]
4Indicate
benefit code claimed (see item 9(c) and amount paid.
Page 5
10.
(f)
Describe the overall cost impact to the health care system, either savings or expenditures,
of using the new service compared to the previous services in (c) and (d) above (e.g.,
fewer hospital days, additional practice costs, etc.).
(g)
Will the implementation of this item result in a shift of services from one sector to
another (e.g., from hospital to fee-for-service)? If so, please indicate which
sectors are involved and the volume of services affected.
(h)
Indicate how the proposed value relates to similar related procedures in the Schedule of
Medical Benefits in terms of time spent with the patient, complexity of the procedure,
responsibility, etc.
ASSOCIATED CHANGES TO THE SCHEDULE OF MEDICAL BENEFITS
(a)
Is this proposed benefit a comprehensive visit or consultation such as defined in General
Rules 4.1, 4.3.1, 4.6.1, 4.6.2., and 4.6.3.?
(b)
Does this proposed item require a tray service as outlined in General Rules 14.1 and 14.2.
If yes, please indicate whether a major or minor tray is applicable.
(c)
Does this item fall under the category of diagnostic surgical procedures as
outlined in General Rule 6.6?
(d)
Is this item a surgical procedure, which should be listed under General Rule 6.8.4e (items
payable at $125.90 if performed under general anaesthesia)?
(e)
Does the proposed item require changes to the General Rules other than those listed
above? If yes, please list the affected rule(s) and changes required.
(f)
Does the proposed item require changes to other item(s) listed in the schedule? If yes,
please list the affected item(s) and the changes required.
(g)
Does the proposed item require any limitations/restrictions in terms of the following:
Age:
Gender:
Specialties:
Accreditation:
Location:
11.
If yes, please detail the applicable locations, see item 4.
OTHER INFORMATION
(a)
Is this procedure beyond the research stage?
Yes
No
(b)
List scientific references describing the procedure:
NOTE: Where applicable please provide photocopies of the scientific references
(articles or relevant sections of textbooks) appropriately referenced.
Page 6
(c)
Is any part of the fee to be paid by a hospital? If so, how much?
(d)
Additional information or comments:
Page 7
PART B:
SECTION APPROVAL
REFERENCE
NUMBER
AMA USE ONLY
1.
Please detail any changes or amendments to original request.
2.
Please detail any changes to utilization estimates:
(a)
First twelve months
(b)
Second twelve months
(c)
Third twelve months
3.
Additional information
4.
Section Approval
Requested by:
Date:
(Please sign)
Approved by:
Date:
President or Section Fees
Committee Chairperson
March 2007
Page 8

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