Billing Desk / Reference edition · October 2026. This is a practical guide, not an adjudication record. Confirm decisions against the linked Alberta Blue Cross sources.
What applies at the counter right now.
Every number links to its Alberta Blue Cross source. Search at the top, or pick what you're doing below. Tap any PIN or code on this site to copy it.
Start here: what are you doing?
Timeline
- Jun 26Clinical services cap in force Active$13,000 per pharmacist across all sites, rolling 28 days by date of service. Pharmacist ID must equal Prescriber ID (else code 76).
- Oct 1New dispensing fees Active$12.35 / $13.50 by days' supply. In-store compounds stay $18.45. The OTC and nutritional changes are postponed (Benefact 1342).
- Oct 1APA PINs retired Active00000081111 and 00000081119 reject. Every pharmacist uses 00000071111 / 00000071119 with the SSC. 00000081116 (SSC K) stays APA-only.
- Oct 1CACP / SMMA reporting ActiveOne ICD-9 plus a new PIN on every initial and follow-up claim. No patient wet signature needed; document consent.
- Oct 1Maintenance Medication List Active84–100 days expected once stable. Shorter fills need eligibility, a form, and an intervention code for MML products.
- Oct 1Topical NSAID compound cap Active$0.55 per gram for diclofenac or an NSAID as the only active ingredient: 00999102 / 00999202 / 00999105 / 00999205. With another active ingredient, bill 00999201 / 00999200, not capped (Benefacts 1341, 1347).
- Oct 1Bill 11 payor order ActivePrivate, employer, NIHB and VAC first. Coverage for Seniors and Non-Group billed last.
- NowFall flu and COVID-19 in pharmacies ActivePharmacies that have vaccine may immunize eligible people now; Public Health starts Oct 19. Pharmacists immunize ages 5+ (Benefacts 1338, 1348).
- Oct 31Transitions endLast day to claim pre-Oct 1 compound stock under 00999202 / 00999205 without the cap, and to use the old SMMA PINs when a new CACP/SMMA PIN errors (Benefact 1347).
- Oct 31MML and daily dispensing forms due DeadlineComplete and keep the Frequent Dispensing and Daily Dispensing Authorization Forms where required. Audits enforce them from Nov 1.
- Mar 31, 2029Framework term endsMulti-year framework between the Government of Alberta and RxA.
Rules people miss
- Claims paid at $0 or partially paid because of the cap cannot be charged to the patient.
- The cap counts by date of service, not submission date. A late claim for a capped period pays $0.
- APA pharmacists now bill renewals and adaptations with 00000071111 too. 00000081111 rejects.
- Days' supply is the whole treatment period: 21 active tablets plus a 7-day break is claimed as 28 days.
- For MML drugs, 2–27 day fills pay at most 2 fees per 28 days per AFR; 28–83 day fills pay at most 1 fee per 28 days.
- MML drugs are not eligible for a daily dispensing fee at all.
- Tobacco care plans are submitted with ICD-9 305, not 305.1.
- The $0.55/g cap covers diclofenac or an NSAID alone, or with lidocaine, menthol, camphor, capsaicin or phenol. Add another active ingredient (e.g. cyclobenzaprine) and it bills under 00999201 / 00999200, not capped.
- Inhalers, eye and ear drops, injectables (except Depo-Provera), topicals and compounds need no MML form for fills under 84 days.
Rolling 28-day cap tracker.
ABC offers no dashboard for the cap and vendors received no specs, so pharmacists track it themselves. Log your clinical service claims from every site you work at. The tracker applies ABC's rule: date of service plus the previous 27 days, $13,000 maximum, partial payment for the claim that crosses the line. Claims are adjudicated in the order you enter them, so a late, backdated claim into a capped period pays $0, as it would at ABC.
- Add each clinical claim, or paste a vendor report
- Read the room left today
- Room comes back as claims pass 28 days
Daily billing and rolling total
Add a claim
Vaccine administration and state-of-emergency continuity assessments are excluded from the cap; they're logged but not counted.
Paste from your vendor report
One claim per line: date,amount,site (site optional). Dates as YYYY-MM-DD.
More
| Date | Site | Service | Billed | Paid | Status |
|---|
This estimates adjudication from what you enter. ABC's real-time adjudication is the record; reversals return value to the window they belonged to.
CACP / SMMA PIN finder.
From October 1, every CACP, SMMA (including Diabetes), SMMA Tobacco and follow-up claim needs one ICD-9 code for the primary condition and one new PIN. APA and non-APA pharmacists use the same PINs. Eligibility hasn't changed, and no patient wet signature is needed (Benefact 1342).
- Pick the service
- Initial or follow-up
- Pathway, or what happened
- Primary condition, then tap the PIN to copy
Still required on every claim
- Special Service Code L (initial) or M (follow-up).
- Initial: service date is the date consent was obtained; submit within 14 days.
- No patient wet signature since Oct 1. Obtain and document consent from the resident or decision maker (M.O. 630/2026, Benefact 1342).
- One initial CACP or SMMA per 365 days; up to 4 follow-ups per 365 days. An SMMA during a CACP period rejects (NJ).
- Keep the most recent completed plan on the record for at least 10 years; give the patient a copy or summary.
- Follow-ups may use any ICD-9 that fits the condition addressed; it doesn't have to be on the initial eligibility list.
- Until Oct 31, 2026: if a new CACP/SMMA PIN gives a claim submission error, you may use the old SMMA Initial or Follow-Up Assessment PIN (Benefact 1347).
Renewal, or care-plan follow-up?
Same clinical act, different claim. Decide by whether a CACP or SMMA follow-up is happening.
| Situation | PIN | SSC | ICD-9 | Fee |
|---|---|---|---|---|
| Ordinary renewal for continuity of care | 00000071111 | F | Not needed | $20 |
| Renewal done as the intervention at a CACP follow-up | 00000012030 | M | Required | $20 |
| Renewal done as the intervention at an SMMA follow-up | 00000022030 | M | Required | $20 |
| Renewal at an SMMA Tobacco follow-up | 00000032010 | M | 305 | $20 |
Only one service claim per patient per day, so it is one or the other, not both. Follow-ups need an initial plan on file (else QL) and count toward the 4-per-year limit.
Reading a PIN at the counter
- 7th digit
- 1 CACP · 2 SMMA (incl. Diabetes) · 3 SMMA Tobacco
- 8th digit
- 1 initial (SSC L) · 2 follow-up (SSC M)
- Initial 9–10th
- pathway (1 discharge, 2 self/RPh, 3 HCP, 4 cont. care) then status (1 unstable, 2 new dx, 3 stable needs review, 4 risk)
- Follow-up 9–10th
- outcome, table below
| Follow-up outcome | CACP / SMMA ends | Tobacco ends |
|---|
Tobacco follow-ups don't follow the CACP/SMMA order. "Stable, no change" is …32090 for tobacco but …2010 for CACP/SMMA. Some staff cheat sheets say the endings are parallel across all three; that holds for CACP and SMMA only.
Worked examples
| Scenario | PIN | SSC | ICD-9 |
|---|---|---|---|
| CACP, pharmacist initiated, stable HTN needing medication review | 00000011230 | L | 401 |
| CACP, heart failure, 9 days after hospital discharge, unstable | 00000011110 | L | 428 |
| SMMA, newly diagnosed type 2 diabetes, pharmacist initiated | 00000021220 | L | 250 |
| SMMA, physician recommends for unstable asthma | 00000021310 | L | 493 |
| SMMA Tobacco, patient asks for help quitting | 00000031200 | L | 305 |
| CACP follow-up, HTN at target, no change | 00000012010 | M | 401 |
| CACP follow-up, diabetes dose change prescribed | 00000012040 | M | 250 |
| CACP follow-up, heart failure, lab ordered | 00000012080 | M | 428 |
| SMMA follow-up, asthma, monitoring / POCT | 00000022090 | M | 493 |
| SMMA follow-up, sent to emergency department | 00000022100 | M | Condition addressed |
| CACP follow-up, ADHD focus, medication renewed | 00000012030 | M | 314 |
The ICD-9 at follow-up can differ from the initial assessment when the focus changes (for example, a diabetes CACP whose follow-up addresses worsening heart failure reports 428).
All 65 new PINs
| PIN | PIN name (as in your software) | SSC | Pathway / outcome |
|---|
| Condition / risk factor | ICD-9 to submit |
|---|
Fees, services & compounds.
Maximum dispensing fees from Oct 1, 2026
| Product | Days' supply | Fee |
|---|---|---|
| Schedule 1 & 2 drugs (incl. compounds bought from a compounding pharmacy) | < 84 | $12.35 |
| Schedule 1 & 2 drugs | 84 or more | $13.50 |
| Compound prepared in-store | any | $18.45 |
| Community Based Naloxone kit | per kit | $12.35 |
| Purchased compound (incl. topical NSAID / diclofenac) | by days | $12.35 / $13.50 |
| Prescribed Schedule 3 / unscheduled OTC (government plans) | any | Pre-Oct 1 rules Postponed |
| Nutritional products, diabetic supplies | any | $0.00 |
Maintenance and daily dispensing rules can reduce an otherwise payable fee to $0. The OTC and nutritional changes in Benefact 1335 are postponed with no new date (Benefact 1342); keep using the pre-October 1 upcharges and fee.
OTC price calculator
Postponed: the October 1 OTC and nutritional changes were delayed for technical reasons (Benefact 1342). "Now" uses the pre-October 1 rules.
| Now (pre-Oct 1 rules) | Postponed change |
|---|
AU#2 is 10% of (MLP or LCAP + AU#1), to a maximum of $100.
Topical NSAID / diclofenac compounds
Benefacts 1341 and 1347, all government-sponsored plans. The $0.55 per gram cap applies when diclofenac or an NSAID is the only active ingredient, with or without lidocaine, menthol, camphor, capsaicin or phenol at any strength. Pick the PIN by what is in the compound.
| Compound | Made in store | Purchased | $0.55/g cap |
|---|---|---|---|
| Diclofenac only (± lidocaine, menthol, camphor, capsaicin, phenol) | 00999102 | 00999202 | Capped |
| Other NSAID only (same add-ons allowed) | 00999105 | 00999205 | Capped |
| Diclofenac or NSAID plus another active ingredient (e.g. cyclobenzaprine) | 00999201 | 00999200 | Not capped |
| Other topical with no diclofenac, NSAID, retinoic acid, salicylic acid, anti-infective or corticosteroid (e.g. 2% diltiazem) | 00999112 | 00999213 | Not capped |
Fees: made in store $18.45; purchased $12.35 (under 84 days) or $13.50 (84+ days). Government monitors the uncapped multi-ingredient PINs. For ingredients not on the Reference Guide, confirm coverage with ABC.
- Made in store: lower of ingredient cost + AU#1, or $0.55/g.
- Purchased: lower of invoice price, or $0.55/g.
- AU#2 continues at 7%, maximum $100.
- Don't use 00999201 / 00999200 for diclofenac or an NSAID with only the add-ons listed above; those stay capped. Amounts above the cap aren't reimbursed (Benefacts 1343, 1347).
- Until Oct 31, 2026: compounds bought or ordered before Oct 1 under 00999202 or 00999205 may be claimed the former way, without the cap. All other claims follow the cap from Oct 1. There is no audit grace period (Benefact 1347).
- Keep the formula and costs, or the supplier invoice, on file. Non-compliant claims may be recovered.
Calculator for capped compounds (00999102 / 00999202 / 00999105 / 00999205)
Benefact 1341 doesn't say whether AU#2 is calculated on the capped amount. This estimate applies it to the capped amount; confirm with ABC Provider Relations (1-800-361-9632) if it matters.
Clinical services: PIN, code, fee and cap status
Since Oct 1: APA PINs 00000081111 and 00000081119 reject. Every eligible pharmacist uses 00000071111 or 00000071119 with the SSC; 00000081116 (SSC K) remains APA-only (Benefact 1342).
| Assessment | SSC | PIN | Max fee | Limit | In $13K cap |
|---|
Fees from the Pharmacist's Guide to Pharmacy Services Compensation, September 2026 (v2).
Maintenance medications
Applies to all government plan members except Palliative Coverage. Once stable, maintenance drugs are expected at 84–100 days. A fee for 84–100 days always pays, subject to the early refill limit: 70% of the previous supply must have elapsed.
- Is the drug on the MML?
- First 3 fills of a new drug or dose?
- Days' supply
- Eligibility reason: get the code and form
Will this fill pay a fee?
| Reason | Code (MML only) | 2–27 d | 28–83 d | Form | Annual limit / AFR | Min. interval |
|---|
Frequency caps on shorter fills
- 2–27 days: max 2 dispensing fees per 28 days per AFR.
- 28–83 days: max 1 dispensing fee per 28 days per AFR.
- Claims that miss the minimum interval are adjusted to a $0 fee.
- Non-MML maintenance drugs need no intervention code, but the signed form is still required to support a shorter-fill fee.
No form needed for these
- Under-84-day fills of inhalers, eye drops, ear drops, injectables (except Depo-Provera), topicals (creams, ointments, gels, lotions) and compounds need no Frequent Dispensing Authorization Form. Quantities must still be clinically appropriate (Benefact 1347).
Authorization form
- Deadline: complete and keep it by Oct 31, 2026; ABC audits enforce it from Nov 1 (Benefact 1342).
- Signed by the patient or agent and the pharmacist; copy to the patient. Use the updated form (Oct 2026) from Forms & print.
- A physician or nurse practitioner may sign instead when the patient is unwilling or unable to sign, the prescriber directed the shorter interval, and, after discussing it with the pharmacist, confirms it is in the patient's best interest. The pharmacist obtains the prescriber's signature (Benefact 1347).
- Renew every 12 months; keep 2 years for audit. Patient can withdraw consent.
- Type B/C continuing care, SLA and Seniors Lodge residents: no form. The facility must be listed on the Assisted Living Navigation Portal; unlisted facilities count as facility living. MML claims for Type B/C and SLA use MY.
Days' supply
- Submit the whole treatment period the quantity covers. A 21-tablet oral contraceptive with a 7-day break is 28 days, not 21 (Benefact 1342).
MML drug categories
ABC adds ingredients to these categories over time. Check the live list before relying on a status.
Exempt from this policy
- Acute or short-term dispensing
- Palliative Coverage members
- Opioid dependence treatment (methadone, buprenorphine/naloxone)
- All Albertans programs: Mifegymiso, CBN naloxone kits, oseltamivir outbreak prophylaxis
Daily dispensing
Applies to all government-sponsored programs administered by ABC. Effective October 1, 2026. Signed forms must be in place by October 31; audits enforce them from November 1 (Benefact 1342).
- Pick the medication type
- What authorization is on file?
- Any other daily fee today?
Can I claim a daily fee?
Checklist
- Maximum 1 daily dispensing fee per patient per day.
- Methadone and buprenorphine/naloxone are exempt from the limit, auto-approved, no form needed.
- Don't claim a daily fee for an opioid when one was already paid for OAT that day. The only exception: the patient gets care through a licensed Narcotic Transition Service (NTS) pharmacy and the opioid is part of a documented NTS protocol. Concurrent prescribing alone doesn't qualify (Benefact 1343).
- Until Dec 1, 2026, refer and enroll eligible patients into NTS, and give information to patients without ready access to an opioid dependency program.
- LIHB plans (Adult and Child Health Benefit, Income Support): non-MML drugs keep their existing days' supply limits for now.
- Form rationale: risk of theft/loss or risk of overuse/abuse. Signed by patient or agent and pharmacist. Update every 3 months.
- Daily Dispensing Authorization Form (ABC)
Vaccines & naloxone.
The 2026–27 fall program and the October changes to Community Based Naloxone claims. Tap a PIN or DIN to copy it.
Fall 2026–27 immunization
- Pharmacies that have received vaccine may immunize eligible people now (Benefact 1348). Primary Care Alberta and Public Health start their public program October 19, 2026. Influenza is funded for all Albertans 6 months and older; pharmacists give provincially funded vaccine to ages 5 and older.
- Provincially funded COVID-19: adults 65+, and people 6 months+ in continuing care or supportive living, with underlying conditions, pregnant, First Nations, Inuit or Métis, health care and other care providers, and teachers. Pharmacies give it to ages 12+.
- Outreach in congregate care can begin once vaccine arrives. A 20% wastage threshold applies.
- Outreach stays the priority: keep vaccine meant for outreach facilities available and don't use it for the general public. Wholesale delivery schedules are unchanged; if you've used your first supply, wait for replenishment orders. Extra supply requests can't be accommodated (Benefact 1348).
| Service | PIN | Product identifier |
|---|---|---|
| Influenza, in pharmacy | 40010002 | Flucelvax, Fluzone: FLU · Fluad: FLU-ADJ |
| Influenza, outreach | 40010007 | — |
| COVID-19, in pharmacy | 40010010 | SpikeVax, Comirnaty: COVIDmRNA · Nuvaxovid: COVIDrSpike |
| COVID-19, outreach | 40010006 | — |
| Vaccine | DIN | Use |
|---|---|---|
| Flucelvax PFS | 02553708 | Standard-dose influenza |
| Fluzone PFS | 02365707 | Standard-dose influenza |
| Fluad | 02362384 | Adjuvanted influenza, 65+ |
| SpikeVax PFS | 02557770 | COVID-19, 12+ · keep frozen; 60 days at 2–8°C once thawed |
| Comirnaty PFS | 02552035 | COVID-19, 12+ · 2–8°C, don't freeze |
| Nuvaxovid PFS | 02558998 | COVID-19, 12+ · max 1 unit (10 doses) a week; expires Dec 2026 |
Reason codes, in priority order: continuing care and supportive living · occupational · other risk · routine recommended · non-provincially funded. Administration fee: up to $13 per injection, $17 in the Outreach program (Compensation Guide, Sep 2026). Vaccine administration is excluded from the $13,000 cap.
Community Based Naloxone kit claims
From October 1, 2026, every CBN kit claim needs the person's own PHN (Benefact 1336).
- DIN
- 02393034
- Carrier
- 16
- Group
- 23464
- Section
- 000
- Quantity
- 1 kit (3 vials); never more than 5 kits a person a day
- Drug benefit fee
- Up to $12.35
- Naloxone cost
- Up to $0.01 per kit
- Reference code
- 86
- Pharmacist gives kit
- Prescriber ID and Pharmacist ID: the pharmacist's licence number
- Technician gives kit
- Prescriber ID 22111PT; Pharmacist ID: the pharmacist's licence number
- No PHN, urgent need
- Pseudo-PHN NX0000000, first name Program, last name Naloxone, any valid date of birth. Only when no PHN is available and no community organization nearby offers kits.
- Kits
- Black CBN kits for the program, kept in the dispensary. Red workplace kits are bought by workplaces.
Claims & coverage
Bill 11: who to bill first
- Ask about every plan: private, employer, retiree, federal programs.
- Bill private and employer plans first. NIHB and Veterans Affairs Canada are also billed before Alberta government plans.
- Bill Coverage for Seniors or Non-Group Coverage last, as payor of last resort.
- Confirm special authorization is in place before submitting, for both private and government plans.
- Explain to patients that government coverage continues; only the order changes.
Bill 11 also requires employers to keep drug and supplemental benefits for actively employed staff 65 and older.
Pharmacy service claim fields
- Group #
- 23464
- Section
- 000
- Carrier code
- 16
- Client ID
- Patient PHN
- Relationship
- 0 if required
- Service date
- Date the service was performed (initial CACP/SMMA: date consent was obtained)
- ICD-9
- Required on CACP/SMMA and follow-ups from Oct 1
- Quantity
- 1
- Pharmacist ID
- Registration # of the pharmacist providing the service
- Prescriber ID
- Must match Pharmacist ID (since Jun 26)
- Prescriber ref ID
- 86
- Fee
- Service fee in the dispensing fee field
Supplies over 100 days and travel
Benefact 1346. No phone call needed for most members: submit a direct bill claim. Up to 200 days is accepted in real time if the member is eligible; coordination of benefits applies at the claim.
| Response | Meaning | What to do |
|---|---|---|
| GD | Not eligible for a quantity authorization | Group 1 or 66 member on the plan under 90 days, no drug history on the plan, coverage ends before the supply does, or palliative care |
| SD | Maximum days' supply allowed is X | Resubmit with the quantity adjusted to X days |
| D9 | Call Adjudicator | Phone ABC for review |
| OU | Refill is X days early | Early refill; use MV only for travel |
| KN | Day supply limit for period exceeded | More than the special authorization period; prescriber may need to renew the SA, or phone ABC |
- MV (vacation supply) is for early refills because of travel, leisure or work, up to 200 days on hand. Not for moving. Some plans cap travel supplies per product per benefit year; that limit can't be overridden.
- For MV, document the early dispense date, the reason, and a summary of your talk with the prescriber, caregiver or patient. Keep it 2 years for audit.
- Phone ABC only for: narcotics or controlled drugs, biologics or high-cost drugs (allow 2 weeks), packaging that can't make the days' supply (e.g. Didrocal kits, insulins, inhalers), and D9 or KN rejections. Have ready: pharmacy licence, member name, date of birth, ABC ID, PHN, DINs, quantity, days' supply, departure and return dates.
- Use judgment on drug availability; dispense a smaller supply when needed to protect supply.
Rejection codes on service claims
| Code | Meaning | Usual fix |
|---|
Forms & printables.
Each form opens the current version straight from Alberta Blue Cross in a new tab. Use your browser's print button there, or download it.
Print from this site
Forms to print and sign
Guides and FAQs
Sources
All links go to Alberta Blue Cross directly, so you always open the current version.
| Document | Date | Covers |
|---|
ABC Pharmacy Services Provider Relations
- Toll free
- 1-800-361-9632
- Edmonton
- 780-498-8370
- Calgary
- 403-294-4041