After Hours Premiums
The After Hours Premiums tariffs (5555, 5553 and 5550) and applicable rules are listed on pages B‑1 and B‑2 of the Physician’s Manual. An After Hours Premium (either 50% or 75%, depending on the time of day/day of the week service is provided) is payable in addition to the fee for a medical service if:
- the medical service commences during the hours set out in the After Hours Premium tariffs, and
- the medical service provided is urgent or emergent.
Subject to certain specified exemptions, After Hours Premiums are payable regardless of where a service is rendered, including:
- In physician’s offices: provided the physician’s office does not maintain regular hours of operation that fall within the periods of time specified in the after hours premiums tariffs, and
- In patients’ homes: even when those services are provided during the regular operating hours of a business dedicated to providing house call services.
Suppose you make a special call during an after hours period to render an urgent/emergent service. After Hours Premiums are calculated based on the total fee for all services rendered during the after hours period. If you claim a special call fee to the appropriate visit/procedure fee, you will apply the appropriate After Hours Premium percentage to the total of these fees.
Services Provided in a Physician’s Office
Suppose you provide an urgent/emergent service in your office during an after hours period. In that case, you may claim an After Hours Premium with respect to that service (subject to the exception noted above). In so doing, you must:
- include the words “urgent/emergent” on your claim, and
- if the ICD code included on the claim does not clearly demonstrate the urgent/emergent nature of the service, include a brief comment to do so.
Perhaps it is unclear to the Manitoba Health staff person who processes the claim whether the service provided was urgent/emergent (based on the ICD code alone or on a combination of the ICD code and the comments included with the claim). In that case, the claim will be referred to a Manitoba Health senior staff member for review.
And if the senior staff member finds it unclear whether the service provided was urgent/emergent, the claim will be rejected. In that case, you will have to query the claim and provide a more detailed explanation of the urgent/emergent nature of the service.
After Hours Premiums apply to telephone, facsimile, and e‑mail claims under Tariff 8000, Tariff 8001 and Tariff 8005 for communications that are of an urgent/emergent nature and take place during an after hours period.
Urgent/Emergent Services Provided While On-Call for Basic “A” or Basic “B” ER/OPD
Physicians who provide on-call coverage of the emergency/out-patient departments of “Basic A” and “Basic B” hospitals can claim after hours premiums where fee-for-service billings are permitted, and the urgent/emergent service is provided during an after hours premium period.
What is Urgent/Emergent?
Since the Physician’s Manual does not contain a definition of “urgent/emergent” service, physicians must consider the nature of each service rendered and use their discretion in determining which services qualify as “urgent/emergent.” In exercising this discretion, some physicians make use of the caep.ca/resources/ctas/implementation-guidelines.
The guidelines used for classifying the acuity of a patient’s condition are nationally recognized and internationally accepted, and are endorsed by the Canadian Association of Emergency Physicians.
These physicians will claim an After Hours Premium if a patient’s condition falls within Level I (resuscitation), Level II (emergent), Level III (urgent) or Level IV (less urgent or semi-urgent) of the guidelines.
Another factor in determining whether a service qualifies as “urgent/emergent” (particularly in relation to house call services) is when the patient’s call was received and what time the service was rendered. The greater the lapse of time between these two events, the less likely the service would qualify as “urgent/emergent”.