Alberta Health claim reconciliations

Alberta Health claim reconciliations

There may be times when claims do not get approved, and additional work will be required before they are accepted by Alberta Health. Typically, a new reconciliation file will be available for the clinic to download every Monday. Downloading this file, and reconciling issues with claims, should be done on a weekly basis.

Step 1. Download the reconciliation file

  1. Click the billing menu, select ‘reconcile’.

  1. Click dial. A message will appear asking if you want to dial and receive the file, click yes.
  2. If a message appears asking to reconcile again, it means there are more files to be downloaded, click dial again.
  3. Repeat this until the message no longer appears.

Once the reconciliation file has been processed, there will be an option to print the following two reports.

  1. General Reconciliation Report – includes all claims that have been assessed in the full dollar amount.
  2. Reconciliation Exceptions Report – includes all claims that have not been paid in full (Adjusted and Refused).  These claims will need to be corrected, and then sent back to AH to be reassessed.

Step 2. Reconcile the claims one by one

Some of the claims will need to be accepted, written off or billed directly to the client or third party. Other claims will need to be corrected and then re-submitted back to Alberta Health.  The reconciliation process will ensure that all claims are assessed accurately and that the financial records within Healthquest are balanced and up to date.

 Open the browse/edit reconciled claims window from the toolbar or under the billing menu.

  1. Select the option for which claims to retrieve, refused is the commonly used option, a list will appear in the bottom half of the window.
    1. All: Displays all claims ever submitted or reconciled in your Healthquest program. 
    2. Refused: Displays only those claims that have been submitted and refused for AH.  Refused claims have been rejected for a variety of reasons.  For example, the diagnostic code may have been invalid/blank, or the BA number may have been entered incorrectly. 
    3. Adjusted: Displays only those claims that have been assessed and paid at a lower amount than was expected. 
    4. Asmt Items/ Held: These options will display claims that are under review from AH. 
  2. Highlight a claim from the list.
  3. Right click on the explanatory code to decipher the reason for refusal or adjustments.

  1. Select the applicable action button based on what the explanatory code suggests:
    1. Re-get Doc - If the practitioner information is the issue (for example, the wrong discipline or skill is entered on the practitioner client card).
      1. Open the practitioner client card, edit their information as needed, and click save.
      2. Close the client card.
      3. Click the ‘Re-get Doc’ button to refresh the practitioner information on the claim.
      4. Click the ‘Ref>>AH’ button to resubmit the claim to Alberta Health.
    2. Re-get Pat - If the patient information is the issue (for example, incorrect PHN or DOB).
      1. Open the patient’s client card, edit their information as needed, and click save.
      2. Close the client card.
      3. Click the ‘Re-get Pat’ button to refresh the patient information on the claim.
      4. Click the ‘Ref>>AH’ button to resubmit the claim to Alberta Health.
    3. Ref>>AH - Sends a refused claim back to Alberta Health after changes have been made. The claim will be given a new claim number and treated as a new claim. Often used after Re-get Doc or Re-get Pat has been used.
    4. Rea>>AH - Sends a claim back to Alberta Health after text has been added (in the Text tab) to justify the price.  No other changes should be made to the claim.  Most often used on claims that have been adjusted.

    1. Del>>AH - Sends a request to Alberta Health to reverse a claim that was billed incorrectly (for example, if AH was billed instead of WCB or the wrong doctor was indicated in a claim. 
    2. Cha>>AH - Sends the claim back to Alberta Health after any other changes have been made.  It may include text although it is not required.  For example, you can use this button if you have changed the service code on a claim and would like to resubmit.

Note: There can be a lot of pop-up messages when sending reconciliations. There is a program setup option to prevent the pop-ups from being so frequent. Program Setup > Billing > AHC > General tab > Suppress messages when sending reconciliations back to AH.

    1. Write off - If there is no way to receive payment for a claim from Alberta Health, select one of the following reasons.
      1. Click ok.
    2. Accept - If happy with the adjustment by Alberta Health Care's decision on the adjusted claim and no further action on the claim can be taken.
    3. Bill to client - opens the invoice entry window to bill the claim amount to a client or third party. For example, if AH was billed in error, use this button to redirect the invoice to the patient. Click to review how to create an invoice for patients and Creating an invoice (

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