18 (1) The General Manager shall determine all issues relating to accounts for insured services in accordance with this Act and shall make the payments from the Plan that are authorized under this Act. 2019, c. 15, Sched. 15, s. 16 (1). Practitioners and health facilities, refuse to pay (2) The General Manager may refuse to pay a claim for payment for an insured service submitted by a practitioner or health facility or may pay a reduced amount in the following circumstances: 1. If the General Manager is of the opinion that all or part of the insured service was not in fact rendered. 2. If the General Manager is of the opinion that the nature of the service is misrepresented, whether deliberately or inadvertently. 3. For a service provided by a practitioner, if the General Manager is of the opinion, after consulting with a practitioner who is qualified to provide the same service, that all or part of the service was not therapeutically necessary. 4. For a service provided by a health facility, if the General Manager is of the opinion, after consulting with a physician or practitioner, that all or part of the service was not medically or therapeutically necessary. 5. If the General Manager is of the opinion that all or part of the service was not provided in accordance with accepted professional standards and practice. 6. In such other circumstances as may be prescribed. 2019, c. 15, Sched. 15, s. 16 (1). Practitioners and health facilities, reimbursement (3) The General Manager may require a practitioner or health facility to reimburse the Plan for an amount paid for a service if, after the payment is made, the General Manager is of the opinion that a circumstance described in subsection (2) exists. 2019, c. 15, Sched. 15, s. 16 (1). Exception (4) Despite subsection (3), the General Manager shall not require a practitioner to reimburse the Plan if the sole reason for requiring the reimbursement is that a circumstance described in paragraph 3 or 5 of subsection (2) exists. 2019, c. 15, Sched. 15, s. 16 (1). Notice, practitioners and health facilities (5) The General Manager shall give notice to a practitioner or health facility of a decision to refuse to pay for a service, to pay a reduced amount or to require that the Plan be reimbursed. 2019, c. 15, Sched. 15, s. 16 (1). Physicians, refusal to pay (6) Under any of the following circumstances, the General Manager may, with respect to a claim for payment for an insured service submitted by a physician, refuse to pay the claim, pay a reduced amount with respect to the claim, pay for the service the General Manager considers to have been provided and not the service described in the claim that was submitted, or, with respect to payment for an insured service that has been made to a physician, request a hearing by the Appeal Board: 1. If the General Manager is of the opinion that any or all of the following apply: i. all or part of the service was not in fact rendered, ii. the service has not been rendered in accordance with the conditions and limitations set out in this Act and the regulations, or iii. there is an absence of a record described in subsection 17.4 (1), (2) or (3). 2. If the General Manager is of the opinion that the nature of the service is misrepresented, whether deliberately or inadvertently. 3. If the General Manager is of the opinion, after consulting with a physician, that all or part of the service was not medically necessary. 4. If the General Manager is of the opinion that all or part of the service was not provided in accordance with accepted professional standards and practice. 5. In such other circumstances as may be prescribed. 2019, c. 15, Sched. 15, s. 16 (1). Notice, physicians (7) Where the General Manager is of the opinion that a circumstance described in subsection (6) exists and has made a decision to refuse to pay for a service or pay a reduced amount to a physician for a service, or to pay for the service the General Manager considers to have been provided and not the service described in the claim, the General Manager shall notify the physician of the decision and the action taken. 2019, c. 15, Sched. 15, s. 16 (1). Physicians, post-payment (8) Where the General Manager has made a payment to a physician for a service and the General Manager is, after providing the physician with the opportunity to provide written submissions, of the opinion that a circumstance described in subsection (6) exists and that reimbursement to the Plan is required, the General Manager may give notice to the Appeal Board requesting it to hold a hearing and at the same time give notice of the request for the hearing to the physician. 2019, c. 15, Sched. 15, s. 16 (1). Not a decision (9) For greater certainty, a refusal to pay under section 17.5 is not a decision for the purposes of this section. 2019, c. 15, Sched. 15, s. 16 (1). Section Amendments with date in force (d/m/y) 1996, c. 1, Sched. H, s. 13 - 01/05/1996 2007, c. 10, Sched. G, s. 8 (1, 2)- 04/09/2007 2019, c. 15, Sched. 15, s. 16 (1) - 10/12/2019