Pay Patient Claim

Notice

Effective February 10, 2022, this form will be updated with a new look and feel, as well as the following new features:

• The Practitioner Number, Payee Number and Specialty Code fields accommodate alphanumeric values for newly issued codes;
• Service Location Codes are mandatory for all claim submissions (claims with a Date of Service of October 1, 2021 or later are no longer accepted with Service Location Code A; please use an alternate Service Location Code for submission); and
• The form accommodates Business Cost Premium claims for Facilities and Practitioners already registered. (Click here for more information.)

The Pay Patient Claim (HLTH 1916) print form has also been updated to include the above changes to the specified fields. HLTH 1916 print form version 3 (rev. August 16, 2012) or earlier are no longer accepted.

Who Can Use This Form

This form is for use by Medical Practitioners registered with MSP who are submitting a claim within 90 days of the date of service and/or Submission Codes A, C, D, I, R, W, or X. This form allows Practitioners to submit claims for services provided to BC residents who are enrolled under MSP. If your claim exceeds 90 days, use the Practitioner Request for Approval of Over-age Claims form (HLTH 2943).

This form is restricted to Medical Practitioners who submit claims for fewer than 2,400 services per year and earn less than $72,000 annually in fee-for-service payments and who do not submit claims to MSP via Teleplan.

When submitting this form, you are declaring that the information provided in the claim form is true and accurate, and you are agreeing to be bound by any authorization or representations made in this claim form.

Form Submission Instructions

Fill out this online form and submit your request electronically.

If you are submitting one of the claim types below, you must submit by mail using the downloadable Fill, Print and Mail form:

• Pay patient claims for opted-out practitioners
• Correctional facility claims
• Claims for patients covered under the Critical Care Coverage Program

To submit eligible dental surgery claims, use the Pay Dentist Claim form.

To submit reciprocal claims, use the Pay Reciprocal Practitioner form.

About Online Forms

At any time before submitting your request, you can click the ‘back’ button at the bottom of each page to return to a previous page, review and/or edit information. You will not lose any information you have entered

Supporting Documentation

You may be required to submit photocopies of supporting documentation to substantiate the adjudication of your claim. This can include:

• Operational reports
• Procedural reports
• Additional correspondence

If you are required to submit supporting documentation, you will be presented with a printable form complete with your information to print, sign and mail with all supporting documentation to Health Insurance BC.

Definitions

Medical Services Claims – note that this is per patient. A separate claim form must be completed for each patient.
Called Start – must use 24-hour clock when inputting information (ie 14:10).
Rendered Finish – must use 24-hour clock when inputting information (ie 14:10).

Fee

There is no fee for this request.

Privacy

Personal information on this form is collected under the authority of the Medicare Protection Act. The information will be used to determine residency in BC and determine eligibility for provincial health care benefits. If you have any questions about the collection of this information, contact Health Insurance BC. Personal information is protected from unauthorized use and disclosure in accordance with the Freedom of Information and Protection of Privacy Act and may be disclosed only as provided by that Act. 

Legislation

All information is subject to change in accordance with the Medicare Protection Act and Regulations and the Hospital Insurance Act and Regulations. If a discrepancy exists between the information Health Insurance BC has provided on this application and the legislation, the legislation will prevail.