(a) may revoke, suspend or cancel a practitioner number issued to a medical practitioner or an oral and maxillofacial surgeon for cause, and

(b) shall revoke or cancel a practitioner number issued to a medical practitioner or an oral and maxillofacial surgeon where the medical practitioner’s or the oral and maxillofacial surgeon’s privileges are revoked by a regional health authority, unless the medical practitioner or the oral and maxillofacial surgeon has been granted privileges by another regional health authority.

(a) on a form provided by the Medicare Branch, or

(b) in an electronic format approved by the Medicare Branch.

(a) whether the participating medical practitioner, the participating oral and maxillofacial surgeon or the beneficiary is to be paid;

(b) the patient’s name;

(c) the patient’s Medicare number;

(d) the patient’s day, month and year of birth;

(e) the patient’s sex;

(f) the beneficiary’s address where the address is different than that on the New Brunswick Medicare Card;

(g) the name and practitioner number of the participating medical practitioner or the participating oral maxillofacial surgeon;

(h) the role the participating medical practitioner or the participating oral and maxillofacial surgeon played in providing the entitled service;

(i) the time spent by the participating medical practitioner or the participating oral and maxillofacial surgeon on the service if that is required to determine the amount of payment;

(j) the name of the transferring or referring

(k) the diagnosis;

(l) the dates of hospital days charged;

(m) the number of hospital days charged;

(n) the date or dates of the entitled service;

(o) whether the entitled service was provided at the participating medical practitioner’s office, patient’s home, in-patient or out-patient department of a hospital facility, nursing home or elsewhere;

(p) the description of the entitled service, the service code for the entitled service and fee charges;

(q) the name of the hospital facility, nursing home or other place where the entitled service was provided;

(r) whether, to the knowledge of the participating medical practitioner or participating oral and maxillofacial surgeon, the entitled service was one for which a claim could be made

(s) the treatment information or remarks;

(t) the signature of the participating medical practitioner, the participating oral and maxillofacial surgeon or designate and the date of the account;

(u) the specific anesthesia modifier to describe the service type;

(v) the service modifier to further define the service rendered;

(w) the vaccine lot number of the immunization being administered;

(x) the on-call code when a participating medical practitioner or participating oral and maxillofacial surgeon submits a fee for service claim provided under the mandated on-call program;

(y) the referral date being the date on which the patient was referred;

(z) the referral type where the participating medical practitioner or participating oral and maxillofacial surgeon indicates whether he or she was referred a patient or whether he or she referred a patient to another practitioner;

(aa) the rotation code where the participating medical practitioner or participating oral and maxillofacial surgeon indicates the on-call rotation code for the specific on-call rotation he or she is covering; and

(bb) the assigned number from the prior consultation process that determines coverage of a service where reasonable doubt exists as to its eligibility as an entitled service.

(a) the patient’s name;

(b) the patient’s Medicare number;

(c) the patient’s day, month and year of birth;

(d) the patient’s sex;

(e) the practitioner number of the participating medical practitioner or the participating oral and maxillofacial surgeon;

(f) the role the participating medical practitioner or participating oral and maxillofacial surgeon played in providing the service;

(g) the time spent by the participating medical practitioner or participating oral and maxillofacial surgeon on the entitled service if that is required to determine the amount of payment;

(h) the identification number assigned by the provincial authority to the transferring or referring

(i) the diagnosis;

(j) the dates of hospital days charged;

(k) the number of hospital days charged;

(l) the date or dates of the entitled service;

(m) whether the entitled service was provided at the participating medical practitioner’s office, patient’s home, in-patient or out-patient department of a hospital facility, nursing home or elsewhere;

(n) the description of the entitled service, the service code for the entitled service and fee charges;

(o) the site code of the hospital facility, nursing home or other place where the service was provided;

(p) whether, to the knowledge of the participating medical practitioner or participating oral and maxillofacial surgeon, the entitled services was one with respect to which a claim could be made;

(q) the date of the account;

(r) the specific anesthesia modifier to describe the service type;

(s) the service modifier to further define the service rendered;

(t) the vaccine lot number of the immunization being administered;

(u) the on-call code when a participating medical practitioner or participating oral and maxillofacial surgeon submits a fee for service claim provided under the mandated on-call program;

(v) the referral date being the date on which the patient was referred;

(w) the referral type where the participating medical practitioner or participating oral and maxillofacial surgeon indicates whether he or she was referred a patient or whether he or she referred a patient to another practitioner;

(x) the rotation code where the participating medical practitioner or participating oral and maxillofacial surgeon indicates the on-call rotation code for the specific on-call rotation he or she is covering; and

(y) the assigned number from the prior consultation process that determines coverage of a service where reasonable doubt exists as to its eligibility as an entitled service.

(a) as a condition of submitting his account in that manner, agree to permit an audit of his books and records by the Medicare Branch,

(b) retain the documentation relating to the account for a period of seven years in a format and manner approved by the Medicare Branch, and

(c) when requested, submit to the Medicare Branch the documentation retained under paragraph (b).

(a) may revoke, suspend or cancel a practitioner number issued to a medical practitioner or an oral and maxillofacial surgeon for cause, and

(b) shall revoke or cancel a practitioner number issued to a medical practitioner or an oral and maxillofacial surgeon where the medical practitioner’s or the oral and maxillofacial surgeon’s privileges are revoked by a regional health authority, unless the medical practitioner or the oral and maxillofacial surgeon has been granted privileges by another regional health authority.

(a) on a form provided by the Medicare Branch, or

(b) in an electronic format approved by the Medicare Branch.

(a) whether the participating medical practitioner, the participating oral and maxillofacial surgeon or the beneficiary is to be paid;

(b) the patient’s name;

(c) the patient’s Medicare number;

(d) the patient’s day, month and year of birth;

(e) the patient’s sex;

(f) the beneficiary’s address where the address is different than that on the New Brunswick Medicare Card;

(g) the name and practitioner number of the participating medical practitioner or the participating oral maxillofacial surgeon;

(h) the role the participating medical practitioner or the participating oral and maxillofacial surgeon played in providing the entitled service;

(i) the time spent by the participating medical practitioner or the participating oral and maxillofacial surgeon on the service if that is required to determine the amount of payment;

(j) the name of the transferring or referring

(k) the diagnosis;

(l) the dates of hospital days charged;

(m) the number of hospital days charged;

(n) the date or dates of the entitled service;

(o) whether the entitled service was provided at the participating medical practitioner’s office, patient’s home, in-patient or out-patient department of a hospital facility, nursing home or elsewhere;

(p) the description of the entitled service, the service code for the entitled service and fee charges;

(q) the name of the hospital facility, nursing home or other place where the entitled service was provided;

(r) whether, to the knowledge of the participating medical practitioner or participating oral and maxillofacial surgeon, the entitled service was one for which a claim could be made

(s) the treatment information or remarks;

(t) the signature of the participating medical practitioner, the participating oral and maxillofacial surgeon or designate and the date of the account;

(u) the specific anesthesia modifier to describe the service type;

(v) the service modifier to further define the service rendered;

(w) the vaccine lot number of the immunization being administered;

(x) the on-call code when a participating medical practitioner or participating oral and maxillofacial surgeon submits a fee for service claim provided under the mandated on-call program;

(y) the referral date being the date on which the patient was referred;

(z) the referral type where the participating medical practitioner or participating oral and maxillofacial surgeon indicates whether he or she was referred a patient or whether he or she referred a patient to another practitioner;

(aa) the rotation code where the participating medical practitioner or participating oral and maxillofacial surgeon indicates the on-call rotation code for the specific on-call rotation he or she is covering; and

(bb) the assigned number from the prior consultation process that determines coverage of a service where reasonable doubt exists as to its eligibility as an entitled service.

(a) the patient’s name;

(b) the patient’s Medicare number;

(c) the patient’s day, month and year of birth;

(d) the patient’s sex;

(e) the practitioner number of the participating medical practitioner or the participating oral and maxillofacial surgeon;

(f) the role the participating medical practitioner or participating oral and maxillofacial surgeon played in providing the service;

(g) the time spent by the participating medical practitioner or participating oral and maxillofacial surgeon on the entitled service if that is required to determine the amount of payment;

(h) the identification number assigned by the provincial authority to the transferring or referring

(i) the diagnosis;

(j) the dates of hospital days charged;

(k) the number of hospital days charged;

(l) the date or dates of the entitled service;

(m) whether the entitled service was provided at the participating medical practitioner’s office, patient’s home, in-patient or out-patient department of a hospital facility, nursing home or elsewhere;

(n) the description of the entitled service, the service code for the entitled service and fee charges;

(o) the site code of the hospital facility, nursing home or other place where the service was provided;

(p) whether, to the knowledge of the participating medical practitioner or participating oral and maxillofacial surgeon, the entitled services was one with respect to which a claim could be made;

(q) the date of the account;

(r) the specific anesthesia modifier to describe the service type;

(s) the service modifier to further define the service rendered;

(t) the vaccine lot number of the immunization being administered;

(u) the on-call code when a participating medical practitioner or participating oral and maxillofacial surgeon submits a fee for service claim provided under the mandated on-call program;

(v) the referral date being the date on which the patient was referred;

(w) the referral type where the participating medical practitioner or participating oral and maxillofacial surgeon indicates whether he or she was referred a patient or whether he or she referred a patient to another practitioner;

(x) the rotation code where the participating medical practitioner or participating oral and maxillofacial surgeon indicates the on-call rotation code for the specific on-call rotation he or she is covering; and

(y) the assigned number from the prior consultation process that determines coverage of a service where reasonable doubt exists as to its eligibility as an entitled service.

(a) as a condition of submitting his account in that manner, agree to permit an audit of his books and records by the Medicare Branch,

(b) retain the documentation relating to the account for a period of seven years in a format and manner approved by the Medicare Branch, and

(c) when requested, submit to the Medicare Branch the documentation retained under paragraph (b).

(a) may revoke, suspend or cancel a practitioner number issued to a medical practitioner or an oral and maxillofacial surgeon for cause, and

(b) shall revoke or cancel a practitioner number issued to a medical practitioner or an oral and maxillofacial surgeon where the medical practitioner’s or the oral and maxillofacial surgeon’s privileges are revoked by a regional health authority, unless the medical practitioner or the oral and maxillofacial surgeon has been granted privileges by another regional health authority.

(a) on a form provided by the Medicare Branch, or

(b) in an electronic format approved by the Medicare Branch.

(a) whether the participating medical practitioner, the participating oral and maxillofacial surgeon or the beneficiary is to be paid;

(b) the patient’s name;

(c) the patient’s Medicare number;

(d) the patient’s day, month and year of birth;

(e) the patient’s sex;

(f) the beneficiary’s address where the address is different than that on the New Brunswick Medicare Card;

(g) the name and practitioner number of the participating medical practitioner or the participating oral maxillofacial surgeon;

(h) the role the participating medical practitioner or the participating oral and maxillofacial surgeon played in providing the entitled service;

(i) the time spent by the participating medical practitioner or the participating oral and maxillofacial surgeon on the service if that is required to determine the amount of payment;

(j) the name of the transferring or referring

(k) the diagnosis;

(l) the dates of hospital days charged;

(m) the number of hospital days charged;

(n) the date or dates of the entitled service;

(o) whether the entitled service was provided at the participating medical practitioner’s office, patient’s home, in-patient or out-patient department of a hospital facility, nursing home or elsewhere;

(p) the description of the entitled service, the service code for the entitled service and fee charges;

(q) the name of the hospital facility, nursing home or other place where the entitled service was provided;

(r) whether, to the knowledge of the participating medical practitioner or participating oral and maxillofacial surgeon, the entitled service was one for which a claim could be made

(s) the treatment information or remarks;

(t) the signature of the participating medical practitioner, the participating oral and maxillofacial surgeon or designate and the date of the account;

(u) the specific anesthesia modifier to describe the service type;

(v) the service modifier to further define the service rendered;

(w) the vaccine lot number of the immunization being administered;

(x) the on-call code when a participating medical practitioner or participating oral and maxillofacial surgeon submits a fee for service claim provided under the mandated on-call program;

(y) the referral date being the date on which the patient was referred;

(z) the referral type where the participating medical practitioner or participating oral and maxillofacial surgeon indicates whether he or she was referred a patient or whether he or she referred a patient to another practitioner;

(aa) the rotation code where the participating medical practitioner or participating oral and maxillofacial surgeon indicates the on-call rotation code for the specific on-call rotation he or she is covering; and

(bb) the assigned number from the prior consultation process that determines coverage of a service where reasonable doubt exists as to its eligibility as an entitled service.

(a) the patient’s name;

(b) the patient’s Medicare number;

(c) the patient’s day, month and year of birth;

(d) the patient’s sex;

(e) the practitioner number of the participating medical practitioner or the participating oral and maxillofacial surgeon;

(f) the role the participating medical practitioner or participating oral and maxillofacial surgeon played in providing the service;

(g) the time spent by the participating medical practitioner or participating oral and maxillofacial surgeon on the entitled service if that is required to determine the amount of payment;

(h) the identification number assigned by the provincial authority to the transferring or referring

(i) the diagnosis;

(j) the dates of hospital days charged;

(k) the number of hospital days charged;

(l) the date or dates of the entitled service;

(m) whether the entitled service was provided at the participating medical practitioner’s office, patient’s home, in-patient or out-patient department of a hospital facility, nursing home or elsewhere;

(n) the description of the entitled service, the service code for the entitled service and fee charges;

(o) the site code of the hospital facility, nursing home or other place where the service was provided;

(p) whether, to the knowledge of the participating medical practitioner or participating oral and maxillofacial surgeon, the entitled services was one with respect to which a claim could be made;

(q) the date of the account;

(r) the specific anesthesia modifier to describe the service type;

(s) the service modifier to further define the service rendered;

(t) the vaccine lot number of the immunization being administered;

(u) the on-call code when a participating medical practitioner or participating oral and maxillofacial surgeon submits a fee for service claim provided under the mandated on-call program;

(v) the referral date being the date on which the patient was referred;

(w) the referral type where the participating medical practitioner or participating oral and maxillofacial surgeon indicates whether he or she was referred a patient or whether he or she referred a patient to another practitioner;

(x) the rotation code where the participating medical practitioner or participating oral and maxillofacial surgeon indicates the on-call rotation code for the specific on-call rotation he or she is covering; and

(y) the assigned number from the prior consultation process that determines coverage of a service where reasonable doubt exists as to its eligibility as an entitled service.

(a) as a condition of submitting his account in that manner, agree to permit an audit of his books and records by the Medicare Branch,

(b) retain the documentation relating to the account for a period of seven years in a format and manner approved by the Medicare Branch, and

(c) when requested, submit to the Medicare Branch the documentation retained under paragraph (b).

(a) may revoke, suspend or cancel a practitioner number issued to a medical practitioner or an oral and maxillofacial surgeon for cause, and

(b) shall revoke or cancel a practitioner number issued to a medical practitioner or an oral and maxillofacial surgeon where the medical practitioner’s or the oral and maxillofacial surgeon’s privileges are revoked by a regional health authority, unless the medical practitioner or the oral and maxillofacial surgeon has been granted privileges by another regional health authority.

(a) on a form provided by the Medicare Branch, or

(b) in an electronic format approved by the Medicare Branch.

(a) whether the participating medical practitioner, the participating oral and maxillofacial surgeon or the beneficiary is to be paid;

(b) the patient’s name;

(c) the patient’s Medicare number;

(d) the patient’s day, month and year of birth;

(e) the patient’s sex;

(f) the beneficiary’s address where the address is different than that on the New Brunswick Medicare Card;

(g) the name and practitioner number of the participating medical practitioner or the participating oral maxillofacial surgeon;

(h) the role the participating medical practitioner or the participating oral and maxillofacial surgeon played in providing the entitled service;

(i) the time spent by the participating medical practitioner or the participating oral and maxillofacial surgeon on the service if that is required to determine the amount of payment;

(j) the name of the transferring or referring

(k) the diagnosis;

(l) the dates of hospital days charged;

(m) the number of hospital days charged;

(n) the date or dates of the entitled service;

(o) whether the entitled service was provided at the participating medical practitioner’s office, patient’s home, in-patient or out-patient department of a hospital facility, nursing home or elsewhere;

(p) the description of the entitled service, the service code for the entitled service and fee charges;

(q) the name of the hospital facility, nursing home or other place where the entitled service was provided;

(r) whether, to the knowledge of the participating medical practitioner or participating oral and maxillofacial surgeon, the entitled service was one for which a claim could be made

(s) the treatment information or remarks;

(t) the signature of the participating medical practitioner, the participating oral and maxillofacial surgeon or designate and the date of the account;

(u) the specific anesthesia modifier to describe the service type;

(v) the service modifier to further define the service rendered;

(w) the vaccine lot number of the immunization being administered;

(x) the on-call code when a participating medical practitioner or participating oral and maxillofacial surgeon submits a fee for service claim provided under the mandated on-call program;

(y) the referral date being the date on which the patient was referred;

(z) the referral type where the participating medical practitioner or participating oral and maxillofacial surgeon indicates whether he or she was referred a patient or whether he or she referred a patient to another practitioner;

(aa) the rotation code where the participating medical practitioner or participating oral and maxillofacial surgeon indicates the on-call rotation code for the specific on-call rotation he or she is covering; and

(bb) the assigned number from the prior consultation process that determines coverage of a service where reasonable doubt exists as to its eligibility as an entitled service.

(a) the patient’s name;

(b) the patient’s Medicare number;

(c) the patient’s day, month and year of birth;

(d) the patient’s sex;

(e) the practitioner number of the participating medical practitioner or the participating oral and maxillofacial surgeon;

(f) the role the participating medical practitioner or participating oral and maxillofacial surgeon played in providing the service;

(g) the time spent by the participating medical practitioner or participating oral and maxillofacial surgeon on the entitled service if that is required to determine the amount of payment;

(h) the identification number assigned by the provincial authority to the transferring or referring

(i) the diagnosis;

(j) the dates of hospital days charged;

(k) the number of hospital days charged;

(l) the date or dates of the entitled service;

(m) whether the entitled service was provided at the participating medical practitioner’s office, patient’s home, in-patient or out-patient department of a hospital facility, nursing home or elsewhere;

(n) the description of the entitled service, the service code for the entitled service and fee charges;

(o) the site code of the hospital facility, nursing home or other place where the service was provided;

(p) whether, to the knowledge of the participating medical practitioner or participating oral and maxillofacial surgeon, the entitled services was one with respect to which a claim could be made;

(q) the date of the account;

(r) the specific anesthesia modifier to describe the service type;

(s) the service modifier to further define the service rendered;

(t) the vaccine lot number of the immunization being administered;

(u) the on-call code when a participating medical practitioner or participating oral and maxillofacial surgeon submits a fee for service claim provided under the mandated on-call program;

(v) the referral date being the date on which the patient was referred;

(w) the referral type where the participating medical practitioner or participating oral and maxillofacial surgeon indicates whether he or she was referred a patient or whether he or she referred a patient to another practitioner;

(x) the rotation code where the participating medical practitioner or participating oral and maxillofacial surgeon indicates the on-call rotation code for the specific on-call rotation he or she is covering; and

(y) the assigned number from the prior consultation process that determines coverage of a service where reasonable doubt exists as to its eligibility as an entitled service.

(a) as a condition of submitting his account in that manner, agree to permit an audit of his books and records by the Medicare Branch,

(b) retain the documentation relating to the account for a period of seven years in a format and manner approved by the Medicare Branch, and

(c) when requested, submit to the Medicare Branch the documentation retained under paragraph (b).

(a) may revoke, suspend or cancel a practitioner number issued to a medical practitioner or an oral and maxillofacial surgeon for cause, and

(b) shall revoke or cancel a practitioner number issued to a medical practitioner or an oral and maxillofacial surgeon where the medical practitioner’s or the oral and maxillofacial surgeon’s privileges are revoked by a regional health authority, unless the medical practitioner or the oral and maxillofacial surgeon has been granted privileges by another regional health authority.

(a) on a form provided by the Medicare Branch, or

(b) in an electronic format approved by the Medicare Branch.

(a) whether the participating medical practitioner, the participating oral and maxillofacial surgeon or the beneficiary is to be paid;

(b) the patient’s name;

(c) the patient’s Medicare number;

(d) the patient’s day, month and year of birth;

(e) the patient’s sex;

(f) the beneficiary’s address where the address is different than that on the New Brunswick Medicare Card;

(g) the name and practitioner number of the participating medical practitioner or the participating oral maxillofacial surgeon;

(h) the role the participating medical practitioner or the participating oral and maxillofacial surgeon played in providing the entitled service;

(i) the time spent by the participating medical practitioner or the participating oral and maxillofacial surgeon on the service if that is required to determine the amount of payment;

(j) the name of the transferring or referring

(k) the diagnosis;

(l) the dates of hospital days charged;

(m) the number of hospital days charged;

(n) the date or dates of the entitled service;

(o) whether the entitled service was provided at the participating medical practitioner’s office, patient’s home, in-patient or out-patient department of a hospital facility, nursing home or elsewhere;

(p) the description of the entitled service, the service code for the entitled service and fee charges;

(q) the name of the hospital facility, nursing home or other place where the entitled service was provided;

(r) whether, to the knowledge of the participating medical practitioner or participating oral and maxillofacial surgeon, the entitled service was one for which a claim could be made

(s) the treatment information or remarks;

(t) the signature of the participating medical practitioner, the participating oral and maxillofacial surgeon or designate and the date of the account;

(u) the specific anesthesia modifier to describe the service type;

(v) the service modifier to further define the service rendered;

(w) the vaccine lot number of the immunization being administered;

(x) the on-call code when a participating medical practitioner or participating oral and maxillofacial surgeon submits a fee for service claim provided under the mandated on-call program;

(y) the referral date being the date on which the patient was referred;

(z) the referral type where the participating medical practitioner or participating oral and maxillofacial surgeon indicates whether he or she was referred a patient or whether he or she referred a patient to another practitioner;

(aa) the rotation code where the participating medical practitioner or participating oral and maxillofacial surgeon indicates the on-call rotation code for the specific on-call rotation he or she is covering; and

(bb) the assigned number from the prior consultation process that determines coverage of a service where reasonable doubt exists as to its eligibility as an entitled service.

(a) the patient’s name;

(b) the patient’s Medicare number;

(c) the patient’s day, month and year of birth;

(d) the patient’s sex;

(e) the practitioner number of the participating medical practitioner or the participating oral and maxillofacial surgeon;

(f) the role the participating medical practitioner or participating oral and maxillofacial surgeon played in providing the service;

(g) the time spent by the participating medical practitioner or participating oral and maxillofacial surgeon on the entitled service if that is required to determine the amount of payment;

(h) the number of the transferring or referring

(i) the diagnosis;

(j) the dates of hospital days charged;

(k) the number of hospital days charged;

(l) the date or dates of the entitled service;

(m) whether the entitled service was provided at the participating medical practitioner’s office, patient’s home, in-patient or out-patient department of a hospital facility, nursing home or elsewhere;

(n) the description of the entitled service, the service code for the entitled service and fee charges;

(o) the site code of the hospital facility, nursing home or other place where the service was provided;

(p) whether, to the knowledge of the participating medical practitioner or participating oral and maxillofacial surgeon, the entitled services was one with respect to which a claim could be made;

(q) the date of the account;

(r) the specific anesthesia modifier to describe the service type;

(s) the service modifier to further define the service rendered;

(t) the vaccine lot number of the immunization being administered;

(u) the on-call code when a participating medical practitioner or participating oral and maxillofacial surgeon submits a fee for service claim provided under the mandated on-call program;

(v) the referral date being the date on which the patient was referred;

(w) the referral type where the participating medical practitioner or participating oral and maxillofacial surgeon indicates whether he or she was referred a patient or whether he or she referred a patient to another practitioner;

(x) the rotation code where the participating medical practitioner or participating oral and maxillofacial surgeon indicates the on-call rotation code for the specific on-call rotation he or she is covering; and

(y) the assigned number from the prior consultation process that determines coverage of a service where reasonable doubt exists as to its eligibility as an entitled service.

(a) as a condition of submitting his account in that manner, agree to permit an audit of his books and records by the Medicare Branch,

(b) retain the documentation relating to the account for a period of seven years in a format and manner approved by the Medicare Branch, and

(c) when requested, submit to the Medicare Branch the documentation retained under paragraph (b).

(a) may revoke, suspend or cancel a practitioner number issued to a medical practitioner or an oral and maxillofacial surgeon for cause, and

(b) shall revoke or cancel a practitioner number issued to a medical practitioner or an oral and maxillofacial surgeon where the medical practitioner’s or the oral and maxillofacial surgeon’s privileges are revoked by a regional health authority, unless the medical practitioner or the oral and maxillofacial surgeon has been granted privileges by another regional health authority.

(a) on a form provided by the Medicare Branch, or

(b) in an electronic format approved by the Medicare Branch.

(a) whether the participating medical practitioner, the participating oral and maxillofacial surgeon or the beneficiary is to be paid;

(b) the patient’s name;

(c) the patient’s Medicare number;

(d) the patient’s day, month and year of birth;

(e) the patient’s sex;

(f) the beneficiary’s address where the address is different than that on the New Brunswick Medicare Card;

(g) the name and practitioner number of the participating medical practitioner or the participating oral maxillofacial surgeon;

(h) the role the participating medical practitioner or the participating oral and maxillofacial surgeon played in providing the entitled service;

(i) the time spent by the participating medical practitioner or the participating oral and maxillofacial surgeon on the service if that is required to determine the amount of payment;

(j) the name of the transferring or referring

(k) the diagnosis;

(l) the dates of hospital days charged;

(m) the number of hospital days charged;

(n) the date or dates of the entitled service;

(o) whether the entitled service was provided at the participating medical practitioner’s office, patient’s home, in-patient or out-patient department of a hospital facility, nursing home or elsewhere;

(p) the description of the entitled service, the service code for the entitled service and fee charges;

(q) the name of the hospital facility, nursing home or other place where the entitled service was provided;

(r) whether, to the knowledge of the participating medical practitioner or participating oral and maxillofacial surgeon, the entitled service was one for which a claim could be made

(s) the treatment information or remarks;

(t) the signature of the participating medical practitioner, the participating oral and maxillofacial surgeon or designate and the date of the account;

(u) the specific anesthesia modifier to describe the service type;

(v) the service modifier to further define the service rendered;

(w) the vaccine lot number of the immunization being administered;

(x) the on-call code when a participating medical practitioner or participating oral and maxillofacial surgeon submits a fee for service claim provided under the mandated on-call program;

(y) the referral date being the date on which the patient was referred;

(z) the referral type where the participating medical practitioner or participating oral and maxillofacial surgeon indicates whether he or she was referred a patient or whether he or she referred a patient to another practitioner;

(aa) the rotation code where the participating medical practitioner or participating oral and maxillofacial surgeon indicates the on-call rotation code for the specific on-call rotation he or she is covering; and

(bb) the assigned number from the prior consultation process that determines coverage of a service where reasonable doubt exists as to its eligibility as an entitled service.

(a) the patient’s name;

(b) the patient’s Medicare number;

(c) the patient’s day, month and year of birth;

(d) the patient’s sex;

(e) the practitioner number of the participating medical practitioner or the participating oral and maxillofacial surgeon;

(f) the role the participating medical practitioner or participating oral and maxillofacial surgeon played in providing the service;

(g) the time spent by the participating medical practitioner or participating oral and maxillofacial surgeon on the entitled service if that is required to determine the amount of payment;

(h) the number of the transferring or referring

(i) the diagnosis;

(j) the dates of hospital days charged;

(k) the number of hospital days charged;

(l) the date or dates of the entitled service;

(m) whether the entitled service was provided at the participating medical practitioner’s office, patient’s home, in-patient or out-patient department of a hospital facility, nursing home or elsewhere;

(n) the description of the entitled service, the service code for the entitled service and fee charges;

(o) the site code of the hospital facility, nursing home or other place where the service was provided;

(p) whether, to the knowledge of the participating medical practitioner or participating oral and maxillofacial surgeon, the entitled services was one with respect to which a claim could be made;

(q) the date of the account;

(r) the specific anesthesia modifier to describe the service type;

(s) the service modifier to further define the service rendered;

(t) the vaccine lot number of the immunization being administered;

(u) the on-call code when a participating medical practitioner or participating oral and maxillofacial surgeon submits a fee for service claim provided under the mandated on-call program;

(v) the referral date being the date on which the patient was referred;

(w) the referral type where the participating medical practitioner or participating oral and maxillofacial surgeon indicates whether he or she was referred a patient or whether he or she referred a patient to another practitioner;

(x) the rotation code where the participating medical practitioner or participating oral and maxillofacial surgeon indicates the on-call rotation code for the specific on-call rotation he or she is covering; and

(y) the assigned number from the prior consultation process that determines coverage of a service where reasonable doubt exists as to its eligibility as an entitled service.

(a) as a condition of submitting his account in that manner, agree to permit an audit of his books and records by the Medicare Branch,

(b) retain the documentation relating to the account for a period of seven years in a format and manner approved by the Medicare Branch, and

(c) when requested, submit to the Medicare Branch the documentation retained under paragraph (b).

(a) may revoke, suspend or cancel a practitioner number issued to a medical practitioner or an oral and maxillofacial surgeon for cause, and

(b) shall revoke or cancel a practitioner number issued to a medical practitioner or an oral and maxillofacial surgeon where the medical practitioner’s or the oral and maxillofacial surgeon’s privileges are revoked by a regional health authority, unless the medical practitioner or the oral and maxillofacial surgeon has been granted privileges by another regional health authority.

(a) on a form provided by the Medicare Branch, or

(b) in an electronic format approved by the Medicare Branch.

(a) whether the participating medical practitioner, the participating oral and maxillofacial surgeon or the beneficiary is to be paid;

(b) the patient’s name;

(c) the patient’s Medicare number;

(d) the patient’s day, month and year of birth;

(e) the patient’s sex;

(f) the beneficiary’s address where the address is different than that on the New Brunswick Medicare Card;

(g) the name and practitioner number of the participating medical practitioner or the participating oral maxillofacial surgeon;

(h) the role the participating medical practitioner or the participating oral and maxillofacial surgeon played in providing the entitled service;

(i) the time spent by the participating medical practitioner or the participating oral and maxillofacial surgeon on the service if that is required to determine the amount of payment;

(j) the name of the transferring or referring

(k) the diagnosis;

(l) the dates of hospital days charged;

(m) the number of hospital days charged;

(n) the date or dates of the entitled service;

(o) whether the entitled service was provided at the participating medical practitioner’s office, patient’s home, in-patient or out-patient department of a hospital facility, nursing home or elsewhere;

(p) the description of the entitled service, the service code for the entitled service and fee charges;

(q) the name of the hospital facility, nursing home or other place where the entitled service was provided;

(r) whether, to the knowledge of the participating medical practitioner or participating oral and maxillofacial surgeon, the entitled service was one for which a claim could be made

(s) the treatment information or remarks;

(t) the signature of the participating medical practitioner, the participating oral and maxillofacial surgeon or designate and the date of the account;

(u) the specific anesthesia modifier to describe the service type;

(v) the service modifier to further define the service rendered;

(w) the vaccine lot number of the immunization being administered;

(x) the on-call code when a participating medical practitioner or participating oral and maxillofacial surgeon submits a fee for service claim provided under the mandated on-call program;

(y) the referral date being the date on which the patient was referred;

(z) the referral type where the participating medical practitioner or participating oral and maxillofacial surgeon indicates whether he or she was referred a patient or whether he or she referred a patient to another practitioner;

(aa) the rotation code where the participating medical practitioner or participating oral and maxillofacial surgeon indicates the on-call rotation code for the specific on-call rotation he or she is covering; and

(bb) the assigned number from the prior consultation process that determines coverage of a service where reasonable doubt exists as to its eligibility as an entitled service.

(a) the patient’s name;

(b) the patient’s Medicare number;

(c) the patient’s day, month and year of birth;

(d) the patient’s sex;

(e) the practitioner number of the participating medical practitioner or the participating oral and maxillofacial surgeon;

(f) the role the participating medical practitioner or participating oral and maxillofacial surgeon played in providing the service;

(g) the time spent by the participating medical practitioner or participating oral and maxillofacial surgeon on the entitled service if that is required to determine the amount of payment;

(h) the number of the transferring or referring

(i) the diagnosis;

(j) the dates of hospital days charged;

(k) the number of hospital days charged;

(l) the date or dates of the entitled service;

(m) whether the entitled service was provided at the participating medical practitioner’s office, patient’s home, in-patient or out-patient department of a hospital facility, nursing home or elsewhere;

(n) the description of the entitled service, the service code for the entitled service and fee charges;

(o) the site code of the hospital facility, nursing home or other place where the service was provided;

(p) whether, to the knowledge of the participating medical practitioner or participating oral and maxillofacial surgeon, the entitled services was one with respect to which a claim could be made;

(q) the date of the account;

(r) the specific anesthesia modifier to describe the service type;

(s) the service modifier to further define the service rendered;

(t) the vaccine lot number of the immunization being administered;

(u) the on-call code when a participating medical practitioner or participating oral and maxillofacial surgeon submits a fee for service claim provided under the mandated on-call program;

(v) the referral date being the date on which the patient was referred;

(w) the referral type where the participating medical practitioner or participating oral and maxillofacial surgeon indicates whether he or she was referred a patient or whether he or she referred a patient to another practitioner;

(x) the rotation code where the participating medical practitioner or participating oral and maxillofacial surgeon indicates the on-call rotation code for the specific on-call rotation he or she is covering; and

(y) the assigned number from the prior consultation process that determines coverage of a service where reasonable doubt exists as to its eligibility as an entitled service.

(a) as a condition of submitting his account in that manner, agree to permit an audit of his books and records by the Medicare Branch,

(b) retain the documentation relating to the account for a period of seven years in a format and manner approved by the Medicare Branch, and

(c) when requested, submit to the Medicare Branch the documentation retained under paragraph (b).

(a) may revoke, suspend or cancel a practitioner number issued to a medical practitioner or an oral and maxillofacial surgeon for cause, and

(b) shall revoke or cancel a practitioner number issued to a medical practitioner or an oral and maxillofacial surgeon where the medical practitioner’s or the oral and maxillofacial surgeon’s privileges are revoked by a regional health authority, unless the medical practitioner or the oral and maxillofacial surgeon has been granted privileges by another regional health authority.

(a) on a form provided by the Medicare Branch, or

(b) in an electronic format approved by the Medicare Branch.

(a) whether the participating medical practitioner, the participating oral and maxillofacial surgeon or the beneficiary is to be paid;

(b) the patient’s name;

(c) the patient’s Medicare number;

(d) the patient’s day, month and year of birth;

(e) the patient’s sex;

(f) the beneficiary’s address where the address is different than that on the New Brunswick Medicare Card;

(g) the name and practitioner number of the participating medical practitioner or the participating oral maxillofacial surgeon;

(h) the role the participating medical practitioner or the participating oral and maxillofacial surgeon played in providing the entitled service;

(i) the time spent by the participating medical practitioner or the participating oral and maxillofacial surgeon on the service if that is required to determine the amount of payment;

(j) the name of the transferring or referring medical practitioner, oral or maxillofacial surgeon, nurse practitioner, optometrist or registered nurse who works in a pre-operative clinic;

(k) the diagnosis;

(l) the dates of hospital days charged;

(m) the number of hospital days charged;

(n) the date or dates of the entitled service;

(o) whether the entitled service was provided at the participating medical practitioner’s office, patient’s home, in-patient or out-patient department of a hospital facility, nursing home or elsewhere;

(p) the description of the entitled service, the service code for the entitled service and fee charges;

(q) the name of the hospital facility, nursing home or other place where the entitled service was provided;

(r) whether, to the knowledge of the participating medical practitioner or participating oral and maxillofacial surgeon, the entitled service was one for which a claim could be made

(s) the treatment information or remarks;

(t) the signature of the participating medical practitioner, the participating oral and maxillofacial surgeon or designate and the date of the account;

(u) the specific anesthesia modifier to describe the service type;

(v) the service modifier to further define the service rendered;

(w) the vaccine lot number of the immunization being administered;

(x) the on-call code when a participating medical practitioner or participating oral and maxillofacial surgeon submits a fee for service claim provided under the mandated on-call program;

(y) the referral date being the date on which the patient was referred;

(z) the referral type where the participating medical practitioner or participating oral and maxillofacial surgeon indicates whether he or she was referred a patient or whether he or she referred a patient to another practitioner;

(aa) the rotation code where the participating medical practitioner or participating oral and maxillofacial surgeon indicates the on-call rotation code for the specific on-call rotation he or she is covering; and

(bb) the assigned number from the prior consultation process that determines coverage of a service where reasonable doubt exists as to its eligibility as an entitled service.

(a) the patient’s name;

(b) the patient’s Medicare number;

(c) the patient’s day, month and year of birth;

(d) the patient’s sex;

(e) the practitioner number of the participating medical practitioner or the participating oral and maxillofacial surgeon;

(f) the role the participating medical practitioner or participating oral and maxillofacial surgeon played in providing the service;

(g) the time spent by the participating medical practitioner or participating oral and maxillofacial surgeon on the entitled service if that is required to determine the amount of payment;

(h) the number of the transferring or referring medical practitioner, oral or maxillofacial surgeon, nurse practitioner, optometrist or registered nurse who works in a pre-operative clinic;

(i) the diagnosis;

(j) the dates of hospital days charged;

(k) the number of hospital days charged;

(l) the date or dates of the entitled service;

(m) whether the entitled service was provided at the participating medical practitioner’s office, patient’s home, in-patient or out-patient department of a hospital facility, nursing home or elsewhere;

(n) the description of the entitled service, the service code for the entitled service and fee charges;

(o) the site code of the hospital facility, nursing home or other place where the service was provided;

(p) whether, to the knowledge of the participating medical practitioner or participating oral and maxillofacial surgeon, the entitled services was one with respect to which a claim could be made;

(q) the date of the account;

(r) the specific anesthesia modifier to describe the service type;

(s) the service modifier to further define the service rendered;

(t) the vaccine lot number of the immunization being administered;

(u) the on-call code when a participating medical practitioner or participating oral and maxillofacial surgeon submits a fee for service claim provided under the mandated on-call program;

(v) the referral date being the date on which the patient was referred;

(w) the referral type where the participating medical practitioner or participating oral and maxillofacial surgeon indicates whether he or she was referred a patient or whether he or she referred a patient to another practitioner;

(x) the rotation code where the participating medical practitioner or participating oral and maxillofacial surgeon indicates the on-call rotation code for the specific on-call rotation he or she is covering; and

(y) the assigned number from the prior consultation process that determines coverage of a service where reasonable doubt exists as to its eligibility as an entitled service.

(a) as a condition of submitting his account in that manner, agree to permit an audit of his books and records by the Medicare Branch,

(b) retain the documentation relating to the account for a period of seven years in a format and manner approved by the Medicare Branch, and

(c) when requested, submit to the Medicare Branch the documentation retained under paragraph (b).

(a) may revoke, suspend or cancel a practitioner number issued to a medical practitioner or an oral and maxillofacial surgeon for cause, and

(b) shall revoke or cancel a practitioner number issued to a medical practitioner or an oral and maxillofacial surgeon where the medical practitioner’s or the oral and maxillofacial surgeon’s privileges are revoked by a regional health authority, unless the medical practitioner or the oral and maxillofacial surgeon has been granted privileges by another regional health authority.

(a) on a form provided by the Medicare Branch, or

(b) in an electronic format approved by the Medicare Branch.

(a) whether the participating medical practitioner, the participating oral and maxillofacial surgeon or the beneficiary is to be paid;

(b) the patient’s name;

(c) the patient’s Medicare number;

(d) the patient’s day, month and year of birth;

(e) the patient’s sex;

(f) the beneficiary’s address where the address is different than that on the New Brunswick Medicare Card;

(g) the name and practitioner number of the participating medical practitioner or the participating oral maxillofacial surgeon;

(h) the role the participating medical practitioner or the participating oral and maxillofacial surgeon played in providing the entitled service;

(i) the time spent by the participating medical practitioner or the participating oral and maxillofacial surgeon on the service if that is required to determine the amount of payment;

(j) the name of the transferring or referring medical practitioner, oral or maxillofacial surgeon, nurse practitioner, optometrist or registered nurse who works in a pre-operative clinic;

(k) the diagnosis;

(l) the dates of hospital days charged;

(m) the number of hospital days charged;

(n) the date or dates of the entitled service;

(o) whether the entitled service was provided at the participating medical practitioner’s office, patient’s home, in-patient or out-patient department of a hospital facility, nursing home or elsewhere;

(p) the description of the entitled service, the service code for the entitled service and fee charges;

(q) the name of the hospital facility, nursing home or other place where the entitled service was provided;

(r) whether, to the knowledge of the participating medical practitioner or participating oral and maxillofacial surgeon, the entitled service was one for which a claim could be made

(s) the treatment information or remarks;

(t) the signature of the participating medical practitioner, the participating oral and maxillofacial surgeon or designate and the date of the account;

(u) the specific anesthesia modifier to describe the service type;

(v) the service modifier to further define the service rendered;

(w) the vaccine lot number of the immunization being administered;

(x) the on-call code when a participating medical practitioner or participating oral and maxillofacial surgeon submits a fee for service claim provided under the mandated on-call program;