A-29, r. 7.2 - Regulation respecting the terms and conditions for the issuance of health insurance cards and the transmittal of statements of fees and claims

Full text
9.2. (Revoked).
O.C. 1116-93, s. 2; O.C. 1040-94, s. 1; 659-2018O.C. 659-2018, s. 5.
9.2. A physician or a dentist entitled to remuneration for insured services by the Board by way of fixed fees or salary, as the case may be, must transmit to the Board a statement of fees that must contain the following elements:
(1)  a preprinted external control number identifying each statement of fees submitted to the Board;
(2)  the full name of the physician or the dentist, as the case may be, and the number attributed to him by the Board;
(3)  the name and numerical code of the establishment or centre, as the case may be, where the physician or the dentist has furnished the service for which he is submitting the statement of fees;
(4)  the period covering the week during which the service was furnished, indicating the dates of the first and last day of the week in question;
(5)  additional information needed by the Board to evaluate the statement of fees pursuant to section 68 of the Act;
(6)  under the heading “SC”, the codes for special cases or special consideration needed by the Board to evaluate the statement of fees pursuant to section 68 of the Act;
(7)  an indication of the number of documents the physician or the dentist has attached to the form he is submitting;
(8)  the information required respecting any service for which a statement of fees is submitted to the Board,
(a)  indicating, for each day in question, the date or, as the case may be, the day of the month for the week in question, a mark designating the alphabetical code representing the work shift in question and, for each mark, the code for the main professional activity and, where applicable, the code for the location where the main professional activity took place, as well as the number of remunerable hours worked;
(b)  the total number of hours worked as declared under subparagraph a;
(c)  where applicable, from among the number of hours declared under subparagraph b, the number of overtime hours of professional activity for which a general practitioner or a dentist, as the case may be, requests to be credited so that he may claim them at a later date;
(d)  where applicable, indicating, for each day in question, the day of the month for the week in question, the duration of a leave, in days and half days, where such is the case, to which the physician or the dentist is entitled under the agreement binding him and which he has not taken, and the code of the leave, insofar as it is not part of a continuous or extended leave as declared in paragraph 11;
(e)  the total number of days of leave, expressed in days and half days, where applicable, as declared under subparagraph d;
(9)  where applicable, indicating the particular day of the month for the week in question, the number of hours of the same type as contemplated in subparagraph c of paragraph 8, accumulated prior to the week in question, which a general practitioner or a dentist, as the case may be, has used because they were credited in accordance with the provisions of the agreement binding him;
(10)  the total number of hours declared under paragraph 9;
(11)  for each period of continuous or extended leave beginning with the week in question, the code and duration, expressed in days and half days, where such is the case, of a leave to which the physician or the dentist is entitled under the agreement binding him and which he has taken, as well as the dates of the first and last day of the period of continuous or extended leave in question;
(12)  reference codes that locate on the form the information provided by the physician or the dentist pertaining to the activities declared under subparagraph a, c or d of paragraph 8 or paragraphs 9 and 11;
(13)  the amount of the benefits which a physician or a dentist already receives from a public retirement plan administered by Retraite Québec, from a social security plan administered by the Commission des normes, de l’équité, de la santé et de la sécurité du travail, Retraite Québec, the Société de l’assurance automobile du Québec or from any other plan to which the establishment or the Board has contributed;
(14)  any remuneration received during a leave taken by the physician or the dentist to serve as juror or witness;
(15)  the signature of the physician or the dentist, as the case may be, or that of his duly authorized mandatary, as well as the date of the signature;
(16)  the signature of a person who is duly authorized by the establishment where the physician or the dentist furnished the service for which he is submitting a statement of fees, as well as the date of the signature.
In addition, where the service is furnished to the following persons:
(a)  an insured person who has not presented his health insurance card;
(b)  an insured person to whom a service is furnished within the scope of the Workmen’s Compensation Act (chapter A-3), the Act respecting industrial accidents and occupational diseases (chapter A-3.001), the Crime Victims Compensation Act (chapter I-6), the Act to promote good citizenship (chapter C-20) or as a result of an accident other than an industrial accident;
(c)  an insured person who received an uninsured service;
(d)  a person who is not an insured person;
(e)  an insured person who holds a valid claim booklet where the service is furnished by a dentist;
the statement of fees must also contain, for each mark designating the alphabetical code representing the work shift in question for each day in question and for each person in question, the following elements:
(1) the insured person’s health insurance number, the year and month of expiry of the insured person’s health insurance card and the serial number of the card or, if not available, the person’s full name at birth, date of birth, sex and address including, where available, the postal code;
(2) the diagnosis or the diagnostic code;
(3) the procedural code or, if not available, the time devoted to the professional activity, in 15-minute segments;
(4) an indication that the service is furnished within the scope of the Workmen’s Compensation Act or the Act respecting industrial accidents and occupational diseases, and the date of the accident or the event, that the service is furnished as a result of an accident other than an industrial accident, or that the service is furnished to an insured person who is not insured or to a person who is not an insured person or did not present a health insurance card;
(5) an indication that the service is furnished within the scope of the Crime Victims Compensation Act or the Act to promote good citizenship and the date of the event;
(6) an indication by the dentist that the insured person holds a valid claim booklet, or that he holds one but did not present it, as well as a reference to the surface and tooth treated, where applicable.
This form may also contain the name of the spouse in the case of a married female insured person, where such name appears on the health insurance card. The form may contain spaces reserved for the use of the Board.
The elements provided for in subparagraphs 1 to 6 of the second paragraph are not required on the statement of fees where the insured service is furnished to an insured person who has not presented his health insurance card, in the following circumstances and cases:
(1)  where the insured person is under 1 year of age;
(2)  where the service is furnished within the scope of the Workmen’s Compensation Act, the Act respecting industrial accidents and occupational diseases, the Act to promote good citizenship, the Crime Victims Compensation Act, the Act respecting assistance and compensation for victims of crime (1993, chapter 54) or as a result of an accident other than an industrial accident:
(a)  where the insured person needs psychiatric services or services furnished within the scope of an intervention plan developed by the institution for that insured person, and the institution operating the centre in which those services are furnished has the health insurance number and the date of expiry of the insured person’s health insurance card, provided that the validity period of the card has not expired;
(b)  where the insured person, at the time he receives the insured service, is in a condition requiring emergency care;
(c)  (subparagraph implicitly revoked; 1992, chapter 57, s. 659);
(d)  where the insured person is lodged by an institution operating a residential and long-term care centre or a rehabilitation centre within the meaning of the Act respecting health services and social services (chapter S-4.2) or where he is sheltered in a reception centre or a hospital centre belonging to the class of hospital centres for long-term care within the meaning of the Act respecting health services and social services for Cree Native persons (chapter S-5) and the regulations made under that Act;
(e)  where the insured person receives an insured service furnished by a physician within the framework of the medical emergency intervention service of the Montréal-Métropolitain region or of the aeromedical evacuation system in Québec;
(f)  where the insured person resides and receives the insured service in a locality or in a territory that is not organized as a locality and that is located north of the 55th parallel.
O.C. 1116-93, s. 2; O.C. 1040-94, s. 1.
9.2. A physician or a dentist entitled to remuneration for insured services by the Board by way of fixed fees or salary, as the case may be, must transmit to the Board a statement of fees that must contain the following elements:
(1)  a preprinted external control number identifying each statement of fees submitted to the Board;
(2)  the full name of the physician or the dentist, as the case may be, and the number attributed to him by the Board;
(3)  the name and numerical code of the establishment or centre, as the case may be, where the physician or the dentist has furnished the service for which he is submitting the statement of fees;
(4)  the period covering the week during which the service was furnished, indicating the dates of the first and last day of the week in question;
(5)  additional information needed by the Board to evaluate the statement of fees pursuant to section 68 of the Act;
(6)  under the heading “SC”, the codes for special cases or special consideration needed by the Board to evaluate the statement of fees pursuant to section 68 of the Act;
(7)  an indication of the number of documents the physician or the dentist has attached to the form he is submitting;
(8)  the information required respecting any service for which a statement of fees is submitted to the Board,
(a)  indicating, for each day in question, the date or, as the case may be, the day of the month for the week in question, a mark designating the alphabetical code representing the work shift in question and, for each mark, the code for the main professional activity and, where applicable, the code for the location where the main professional activity took place, as well as the number of remunerable hours worked;
(b)  the total number of hours worked as declared under subparagraph a;
(c)  where applicable, from among the number of hours declared under subparagraph b, the number of overtime hours of professional activity for which a general practitioner or a dentist, as the case may be, requests to be credited so that he may claim them at a later date;
(d)  where applicable, indicating, for each day in question, the day of the month for the week in question, the duration of a leave, in days and half days, where such is the case, to which the physician or the dentist is entitled under the agreement binding him and which he has not taken, and the code of the leave, insofar as it is not part of a continuous or extended leave as declared in paragraph 11;
(e)  the total number of days of leave, expressed in days and half days, where applicable, as declared under subparagraph d;
(9)  where applicable, indicating the particular day of the month for the week in question, the number of hours of the same type as contemplated in subparagraph c of paragraph 8, accumulated prior to the week in question, which a general practitioner or a dentist, as the case may be, has used because they were credited in accordance with the provisions of the agreement binding him;
(10)  the total number of hours declared under paragraph 9;
(11)  for each period of continuous or extended leave beginning with the week in question, the code and duration, expressed in days and half days, where such is the case, of a leave to which the physician or the dentist is entitled under the agreement binding him and which he has taken, as well as the dates of the first and last day of the period of continuous or extended leave in question;
(12)  reference codes that locate on the form the information provided by the physician or the dentist pertaining to the activities declared under subparagraph a, c or d of paragraph 8 or paragraphs 9 and 11;
(13)  the amount of the benefits which a physician or a dentist already receives from a public retirement plan administered by the Régie des rentes du Québec, from a social security plan administered by the Commission de la santé et de la sécurité du Travail, the Commission administrative des régimes de retraite et d’assurance, the Société de l’assurance automobile du Québec or from any other plan to which the establishment or the Board has contributed;
(14)  any remuneration received during a leave taken by the physician or the dentist to serve as juror or witness;
(15)  the signature of the physician or the dentist, as the case may be, or that of his duly authorized mandatary, as well as the date of the signature;
(16)  the signature of a person who is duly authorized by the establishment where the physician or the dentist furnished the service for which he is submitting a statement of fees, as well as the date of the signature.
In addition, where the service is furnished to the following persons:
(a)  an insured person who has not presented his health insurance card;
(b)  an insured person to whom a service is furnished within the scope of the Workmen’s Compensation Act (chapter A-3), the Act respecting industrial accidents and occupational diseases (chapter A-3.001), the Crime Victims Compensation Act (chapter I-6), the Act to promote good citizenship (chapter C-20) or as a result of an accident other than an industrial accident;
(c)  an insured person who received an uninsured service;
(d)  a person who is not an insured person;
(e)  an insured person who holds a valid claim booklet where the service is furnished by a dentist;
the statement of fees must also contain, for each mark designating the alphabetical code representing the work shift in question for each day in question and for each person in question, the following elements:
(1) the insured person’s health insurance number, the year and month of expiry of the insured person’s health insurance card and the serial number of the card or, if not available, the person’s full name at birth, date of birth, sex and address including, where available, the postal code;
(2) the diagnosis or the diagnostic code;
(3) the procedural code or, if not available, the time devoted to the professional activity, in 15-minute segments;
(4) an indication that the service is furnished within the scope of the Workmen’s Compensation Act or the Act respecting industrial accidents and occupational diseases, and the date of the accident or the event, that the service is furnished as a result of an accident other than an industrial accident, or that the service is furnished to an insured person who is not insured or to a person who is not an insured person or did not present a health insurance card;
(5) an indication that the service is furnished within the scope of the Crime Victims Compensation Act or the Act to promote good citizenship and the date of the event;
(6) an indication by the dentist that the insured person holds a valid claim booklet, or that he holds one but did not present it, as well as a reference to the surface and tooth treated, where applicable.
This form may also contain the name of the spouse in the case of a married female insured person, where such name appears on the health insurance card. The form may contain spaces reserved for the use of the Board.
The elements provided for in subparagraphs 1 to 6 of the second paragraph are not required on the statement of fees where the insured service is furnished to an insured person who has not presented his health insurance card, in the following circumstances and cases:
(1) where the insured person is under 1 year of age;
(2) where the service is furnished within the scope of the Workmen’s Compensation Act, the Act respecting industrial accidents and occupational diseases, the Act to promote good citizenship, the Crime Victims Compensation Act, the Act respecting assistance and compensation for victims of crime (1993, chapter 54) or as a result of an accident other than an industrial accident:
(a) where the insured person needs psychiatric services or services furnished within the scope of an intervention plan developed by the institution for that insured person, and the institution operating the centre in which those services are furnished has the health insurance number and the date of expiry of the insured person’s health insurance card, provided that the validity period of the card has not expired;
(b) where the insured person, at the time he receives the insured service, is in a condition requiring emergency care;
(c) (subparagraph implicitly revoked; 1992, chapter 57, s. 659);
(d) where the insured person is lodged by an institution operating a residential and long-term care centre or a rehabilitation centre within the meaning of the Act respecting health services and social services (chapter S-4.2) or where he is sheltered in a reception centre or a hospital centre belonging to the class of hospital centres for long-term care within the meaning of the Act respecting health services and social services for Cree Native persons (chapter S-5) and the regulations made under that Act;
(e) where the insured person receives an insured service furnished by a physician within the framework of the medical emergency intervention service of the Montréal-Métropolitain region or of the aeromedical evacuation system in Québec;
(f) where the insured person resides and receives the insured service in a locality or in a territory that is not organized as a locality and that is located north of the 55th parallel.
O.C. 1116-93, s. 2; O.C. 1040-94, s. 1.