What does EOB code 44 mean on a Manitoba Health claim, and how do I fix it?

The reason codes

When it applies / when it does not

EOB stands for Explanation of Benefits. It is the reason code Manitoba Health puts next to a claim on your remittance advice. That is the statement it sends each pay period (at mid-month and month end). (CLMST-4)

What code 44 means

• Manitoba Health's list of codes says: "This claim was refused as the patient's demographics submitted does not match our information under this PHIN." The PHIN is the patient's health number. (Explanation of Benefit Codes, page 32)
• "Demographics" means the patient details on the claim. Manitoba Health's claims FAQ says: "Every claim should have the following six (6) fields correctly completed for patient demographics". (Manitoba Health, FAQ - Claims Processing System) The six fields are:
  • PHIN
  • Registration number
  • Birth date
  • Gender
  • Given name
  • Surname
• A name change is one example Doctors Manitoba gives. The patient may not have told Manitoba Health yet, or the change may not be on record. In that case Doctors Manitoba says to "submit the claims using the information shown on the Manitoba health card presented by the patient." It also says to ask the patient to report the change to Manitoba Health. (Doctors Manitoba, EOB 44 practical guidelines)

How to fix it

• A refused claim is fixed by sending a corrected one. The manual says: "Claims that require a correction to the initial claim must be electronically submitted with the necessary corrections noted in the EOB within six months from the date of the service." (CLMST-1, item 9)
• The six months run from the date of service, not from the date of the refusal. "All claims MUST be submitted within six (6) months of the date of the service." (CLMST-1, item 4)
• A corrected claim sent after six months is refused again. Claims received more than six months after the service date "will be rejected with Explanation of Benefits (EOB) code “C2”." (CLMST-3)
• An extension is possible only in "extenuating circumstances". You must ask in writing and give details. Send the request to the Director of Insured Benefits at Manitoba Health. (CLMST-3)

What not to do

• Do not send a query for code 44. "A query should not be submitted for claims that require a correction." (CLMST-1, item 9) A query is for a claim you think was assessed or paid wrongly. You may send it within six months of the date on the remittance advice. (CLMST-1, item 8)

Who to call

• If you do not know which detail is wrong, ask Manitoba Health. Doctors Manitoba says Manitoba Health will help physicians get accurate patient details. Complete a "529" form (Request for Manitoba Health Registration Number) and fax or mail it to Manitoba Health. (Doctors Manitoba, EOB 44 practical guidelines)
• If the patient cannot give you their PHIN, the manual says to direct them to Registration/Client Services at 204-786-7101 or 1-800-392-1207. (CLMST-3)
• The manual makes the physician responsible for reviewing EOB codes and reconciling each remittance advice on time. (CLMST-4)
• Questions about a remittance advice go to Claims Enquiry at 204-786-7355. (CLMST-5)

Worked example

What is often not billed

The visit itself. A claim refused with code 44 has to be corrected and sent again within six months of the date of service. (CLMST-1, items 4 and 9) A claim resent after six months is refused with code C2, unless an extension is granted. (CLMST-3) The corrected claim needs patient details that match Manitoba Health's records (Explanation of Benefit Codes, page 32). Our suggestion, not a Manitoba Health rule: change only the patient details. Send the corrected claim with the same date of service and tariff as the first claim.