Schedule of Medical Benefits Change Request Form

REFERENCE
NUMBER

PART A: PHYSICIAN REQUEST

AAMA 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 preservice consults or visits are usually provided.

Associated Patient Encounters /

Health Service Code

/ Average Number / $ Value
Hospital
Office

(b)  Intra-service component

Physician time component (specific to the proposed procedure):

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 / Health Service Code / Average Number / $ Value
Hospital
Office
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) Technician[1] time component
Minimum Time / Maximum Time / Average Time / $ Value
Technician
Technical Discipline
Hourly Rate

(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
(iii) Other costs[2] (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]
(c) Total Technical Fee (a, b(i), (ii), (iii)

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 / Pre-operative / Post-operative
C / 0 - Days / 0 - Days
R / 0 - Days / 0 - Days
V / 0 - Days / 0 - Days
T / 0 - Days / 0 - Days
M / 0 - Days / 0 – Days
M+ / 0 – Days / 0 - Days
1 / 0 - Days / 14 - Days
3 / 7 - Days / 7 - Days
4 / 7 - Days / 14 - Days
6 / 14 - Days / 14 - Days
14 / 30 - Days / 14 - Days
15 / 0 - Days / 7 - Days

8. 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 Advisory[4]
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)]

(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 feeforservice)? 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.

10. 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: / If yes, please detail the applicable locations, see item 4.

11. 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.

(c) Is any part of the fee to be paid by a hospital? If so, how much?

(d) Additional information or comments:

Page 2

PART B: SECTION APPROVAL REFERENCE NUMBER

AAMA 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

[1]Complete 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.

[2]Cost not covered in specific procedure but common to all procedures, e.g., receptionist, billing clerk.

[3]Please provide details of all other costs that were included.

[4]Indicate benefit code claimed (see item 9(c) and amount paid.