Common use of Service Information Clause in Contracts

Service Information.  Service Visit Date  Mode of service Face-to face, telephone, etc.  Responsibility for payment Used to exclude federal govt., WCB, etc.  Main and secondary diagnoses ICD10-CA codes  Main and other interventions and attributes CCI procedure codes and attributes  Type of Anesthetic Identifies the type used for interventions (general, spinal, local, etc.)  Provider types NACRS code assigned to provider type (MD, Dentist, RN, etc.)  Doctor name and identifier Physician specific information  Admit via Ambulance Used if a Client is brought to the service delivery site by ambulance  Institution from and institution to Used when a Client is transferred from or to another acute care facility  Visit disposition Discharged, admitted, left without being seen, etc. Schedule “D” Appendix 2 Additional Elements Required for Data Management (XXX) Client Identifying Information  Province Client’s Home Province AB, BC, SK, MB, NL, PE, NS, NB, QC, ON, NT, YT, NU, US, OC (Other Country), NR (Unsp. Non-resident) Service Information  Facility Code AHS provided code that indicates service being provided.  Facility Fee Dollar value of service being provided  Alberta Health Physician Fee Billing Code Alberta Health Physician Service Fee code that further defines facility code Regional standard format and submission method remains as is via excel file and email. NOTE: Submission method may be adjusted in accordance with security standards of AHS. Schedule “D” Appendix 3

Service Information.  Service Visit Date  • Mode of service Face-to face, telephone, etc.  • Responsibility for payment Used to exclude federal govt., WCB, etc.  • Main and secondary diagnoses ICD10-CA codes  • Main and other interventions and attributes CCI procedure codes and attributes  • Type of Anesthetic Identifies the type used for interventions (general, spinal, local, etc.)  • Provider types NACRS code assigned to provider type (MD, Dentist, RN, etc.)  • Doctor name and identifier Physician specific information  • Admit via Ambulance Used if a Client is brought to the service delivery site by ambulance  • Institution from and institution to Used when a Client is transferred from or to another acute care facility  • Visit disposition Discharged, admitted, left without being seen, etc. Schedule “D” Appendix 2 Additional Elements Required for Data Management (XXX) Client Identifying Information  • Province Client’s Home Province AB, BC, SK, MB, NL, PE, NS, NB, QC, ON, NT, YT, NU, US, OC (Other Country), NR (Unsp. Non-resident) Service Information  • Facility Code AHS provided code that indicates service being provided.  • Facility Fee Dollar value of service being provided  • Alberta Health Physician Fee Billing Code Alberta Health Physician Service Fee code that further defines facility code Regional standard format and submission method remains as is via excel file and email. NOTE: Submission method may be adjusted in accordance with security standards of AHS. Schedule “D” Appendix 3