< Error codes

Error code

52 — Fee-for-service assessed by medical consultant

Set by medical consultant

A Ministry medical consultant assessed this claim and set the payment instead of it being paid automatically.

What to do: To dispute it, send a remittance advice inquiry with the clinical records within 7 months, not a new claim.

Code
52
Description
Fee-for-service assessed by medical consultant

Explanation

Updated October 26, 2026

A Ministry medical consultant reviewed this claim and set the payment. To dispute it, send an inquiry with the clinical records, not a new claim.

What it means

Code 52 is an explanatory code on the Remittance Advice (RA). It means the fee-for-service claim was assessed by a Ministry medical consultant instead of being paid automatically. The amount on the line is the result of that review.

The Schedule of Benefits sends some claims to a medical consultant by design. Services listed as IC (independent consideration) are priced by the medical consultant from a supporting letter and an operative or consultation report (GP12). Detention (K001) is assessed by a medical consultant on an IC basis and needs a written explanation (GP31). For R533 the Schedule says claims are assessed by the Medical Consultant (N28).

Because the claim has already been reviewed, sending it again as a new claim won't change the result. If you disagree, use the Ministry's inquiry process and send the records the consultant needs.

Common causes

  • An IC service, such as R990 or R993, priced by the consultant from the documents sent
  • A service the Schedule says is assessed by a medical consultant, such as detention (K001) or R533
  • A claim flagged for manual review, with supporting documents
  • Documents that didn't show why the service, time or complexity justified the amount claimed

How to fix it

  1. Compare the amount paid with the amount claimed. If you accept the result, there is nothing to do.
  2. If you disagree, send a Remittance Advice Inquiry (RAI) through eSubmit, or on form 0918-84, within 7 months of the date of the RA the claim appears on. Explain why you think the payment is wrong.
  3. Attach what the consultant needs to see: the clinical notes or operative report, start and stop times for time-based services, and for IC services a letter comparing the procedure with listed ones.
  4. The Ministry answers on the RAI: paid correctly, adjustment required, or final decision. If the answer isn't marked final, keep the same inquiry going by sending new information. Don't open a second RAI for the same claim.
  5. If the Ministry makes a final decision and you still disagree, you can ask for an appeal. The deadline is short and counts from the date of the decision, so act as soon as it arrives.

Don't resubmit if

  • The claim is on the RA. A new claim would be a duplicate; use an RAI.
  • You have nothing new to send. The same documents will usually get the same answer.

How APEX handles it

APEX shows 52 on the claim line and has no correction rule for it. A line that was paid something is not added to the Correction Centre. If nothing on the visit was paid, the visit is listed under Outstanding for you to review; APEX never sends it on its own. If you are handling it through an RAI instead, use Ignore on it so it isn't sent again as a new claim. APEX doesn't write the inquiry or send records for you. See how APEX works · Pricing

Related codes: 46, 47, 49, 62, 54

Sources