The 18 AHCIP rules in v12

v12 of the Zorva prompt ships with 18 AHCIP rules covering the highest-yield patterns Alberta billers see on every claim. Here's the list, grouped by severity, with the rule code and a one-line description of what it catches.

High-severity (10 rules)

• AH-MOD-25 — Modifier-25 misapplication: an E/M code billed with a procedure on the same day without documentation of a separately identifiable service.
• AH-TELE-01 — Telehealth consent missing or expired (HIA Schedule 1 requirement).
• AH-CG-01 — Comprehensive/General Assessment (CMGP) billed when the documentation only supports a focused visit.
• AH-DX-01 — Diagnosis code does not support the billed fee code (AHCIP GR 4.4).
• AH-NPI-01 — Referring practitioner NPI missing or invalid on a referral-required service.
• AH-INS-01 — Service billed to AHCIP for a non-insured service (e.g. third-party request, cosmetic).
• AH-LAB-01 — Lab code billed without documentation of the test being performed.
• AH-TIME-01 — Time-based code billed without the required start/stop time documentation.
• AH-REF-01 — Service requiring a referral submitted without an attached referral letter.
• AH-PHIA-01 — Clinical note contains a patient identifier that hasn't been de-identified per the HIA Information Manager Agreement.

Medium-severity (5 rules)

• AH-ADDON-01 — Add-on code eligible based on the primary code but missing from the claim.
• AH-AFTER-01 — After-hours premium documented but not on the claim.
• AH-PRV-01 — Service billed under the wrong practitioner (specialty mismatch).
• AH-CONS-01 — Consultation code (03.xx) billed but the referral pattern doesn't support a consult.
• AH-FUP-01 — Follow-up visit within the AHCIP-stamped window, billed as a new visit.

Low-severity (3 rules)

• AH-COPY-01 — Duplicate claim submission (same patient, same service, same day).
• AH-MOD-01 — Modifier present but not supported by the documentation (informational).
• AH-PRG-01 — Procedure code maps to a deprecated AHCIP GR; the modern equivalent should be used.

What's deliberately not in v12

We don't catch everything. The 18 rules above are the ones that, across the 19-encounter shadow audit, had the highest yield (most revenue recovered) and the lowest false-positive rate. The full long-tail — uncommon modifiers, specialty-specific GR nuances, regional pilot codes — is on the v13 and v14 roadmap.

If a rule you need isn't on this list, the request goes to the same kanban board the rest of the rule backlog lives on. We tune the prompt quarterly with pilot clinics.