OHIP error codes and explanatory codes

Incorrect District code 0 Correct & resubmit

Administrative

Date of service does not match OP report-correct & resubmit

Administrative

Special Visit premium payable only when submitting with FSC from the general listings

Coding problem

No receipt of supporting documentation requested by MOH

Administrative

Fee Schedule Code(s) used is not correct, please resubmit claim with the appropriate FSC or submit an RAI if the claim is posted on a Remittance Advice

Coding problem

Resubmit as RMB Claim

Administrative

Bill Patient or Quebec Medicare

Patient information

Please advise Patient to contact MOH re eligibility /card status/address

Patient information

Service date is prior to newborn's date of birth

Patient information

Fee billed low-check for current SOB fee

Administrative

No. of Services exceed Maximum allowed

Not re-billable

Cannot be claimed alone/service date mismatch

Coding problem

E409/E410 N/A-Resubmit with appropriate assist/anaesthetic premium codes

Coding problem

Resubmit with man review indicator and provide supporting documentation for two assistants

Administrative

Resubmit with manual review indicator and forward copy of OP Report

Administrative

Resubmit with manual review documentation i.e. consultation report/Hospital Records

Administrative

Records indicate patient deceased/ Please clarify or confirm.

Patient information

Code submitted requires prior approval

Administrative

Hospital visits claimed by more than one physician-please clarify role in patient's care

Not re-billable

Claims appearing on previous RA’s as over/under payments should not be resubmitted. Submit your inquiry electronically using eSubmit or fax the ministry using the “Remittance Advice Inquiry” form (0918-84) to your claims processing office. This form is available online.

Not re-billable

Incomplete newborn registration-have parent/guardian contact MOH

Patient information

One house call assessment (A901) allowed per visit. Please resubmit claim with appropriate service code

Coding problem

This duplication submission is being returned; Original submission currently on file pending medical consultant adjudication

Not re-billable

Resubmit the claim with Manual Review Indicator Submit your written explanation for total time spent with patient including consultation/assessment indicated using eSubmit or fax the ministry using the “Claims Flagged for Manual Review” form (2404-84) to your claims processing office. This form is available online.

Administrative

Discrepancy between claim and documentation. Resubmit claim and documentation.

Administrative

Explanation of benefits required

Administrative

Diagnosis required

Diagnostic code

Return with agency claim submission form

Administrative

Complete translation required

Administrative

Itemized breakdown for all charges required

Administrative

Explanation of benefits/invoice total mismatch

Administrative

Outside Service Period

Coding problem

Outside of Age Limit Patient is underage or overage for this service code

Coding problem

Wrong Sex for Service This service is not normally performed for this sex. Please check your records.

Coding problem

Multiple duplicate claims

Not re-billable

Claimed by Other Practioner

Not re-billable

No such service code for date of service

Coding problem

No fee exists for this service code on this date of service

Coding problem

Fee Billed Low

Administrative

Maximum Number Services per the Fee Schedule Master (FSM)

Not re-billable

X-Ray Code Maximum Number Services per the Fee Schedule Master (FSM)

Not re-billable

Other New Patient Fee Already Paid

Not re-billable

Invalid specialty for this service code

Provider registration

Maximum reached-resubmit alternate Fee Schedule Code (FSC)

Coding problem

Unaccepted Referral Number. Not 6 numerics Equal to the Practitioner billing number Referring number is 722900-744292 (Nurse Practitioner (NP)) and FSC is not eligible for NP referral. Referring number is 700000-722899 (Midwife (MW)) and FSC is not eligible for MW referral.

Administrative

Not allowed with visit

Coding problem

Procedure allowed previously

Not re-billable

Not allowed alone

Coding problem

Premium not allowed alone

Coding problem

Corresponding Procedure Invalid, Omitted or Paid at zero

Coding problem

Cannot be billed together

Coding problem

Invalid Admission Date and/or Hospital number.

Administrative

Concurrent or Supportive Care Same Period

Not re-billable

Service Limit Exceeded

Not re-billable

Minimum service requirements have not been met

Not re-billable

Multiple Procedures

Coding problem

Previous Obstetrical Service

Coding problem

Most Responsible Physician (MRP) Visit Already Paid

Not re-billable

Missing Physician Referring Number

Administrative

Referring Physician Number Required

Administrative

Not Allowed with Surgical Procedure

Coding problem

Only One Modality Allowed

Coding problem

Must Include Video Modality

Coding problem

No Patient-Physician Relationship

Coding problem

Modality Not Allowed

Coding problem

Counselling Not Allowed

Depends on the claim

ICHSC number not approved for billing on the date specified

Provider registration

ICHSC not licensed or grandfathered to bill FSC on the date specified

Provider registration

Insured services are excluded from ICHSC billings

Provider registration

Provider is not approved to bill ICHSC fee on date specified

Provider registration

ICHSC practitioner 991000 is not allowed to bill insured services

Provider registration

Referring physician number is required for the ICHSC fee billed

Provider registration

'I' service codes are exclusive to ICHSCs

Provider registration

Mobile site number required

Provider registration

Group not Eligible

Depends on the claim

Service Date before Eligibility Effective Date

Patient information

Mismatched Version Code

Patient information

Service Date after Eligibility End Date

Patient information

Service Date Not in Eligibility Period

Patient information

Eligibility Terminated-Deceased

Patient information

Health Number (HN) Not Activated

Patient information

Invalid FSC for Nurse Practitioner (NP)

Depends on the claim

Enrolment Transaction Not Allowed

Depends on the claim

Not for Enrolment/ReEnrolment

Depends on the claim

Incorrect Service Date Check Date of Enrolment

Depends on the claim

Enrolment Restriction Applied

Depends on the claim

Incorrect FSC for Group Type

Depends on the claim

Health Number (HN) Not Activated

Patient information

Code must be billed alone

Depends on the claim

Network billing not approved

Depends on the claim

Patient not rostered/rostered to another Network

Depends on the claim

Enrolment Date Mismatch

Depends on the claim

Incorrect Code for Eligibility (Ontario Works/Ontario Disability Support Program)

Depends on the claim

Patient Not Eligible for Program

Patient information

Clinic/Doctor Not on File Practitioner not registered with OHIP

Provider registration

Specialty mismatch Specialty Code is inactive or not registered on date of service

Provider registration

Claim submitted as Pay Patient Health care provider is registered as OPTED-IN for date of service

Provider registration

Claim submitted as Pay Provider Health care provider is registered as OPTED-OUT for date of service

Provider registration

Lab inactive on Service date

Provider registration

Incorrect Referral Number Referring/requisitioning health care provider number is not registered with the Ministry of Health

Provider registration

Lab Number not on File

Provider registration

Solo practitioner inactive on service date Practitioner number is Midwife (700000-722899) referral only Claims submitted by Chiropractors using their Claim Submission Number (CSN) Physician Registered as group billing only

Provider registration

Group not registered

Provider registration

Group inactive on service date

Provider registration

Affiliated Practitioner not in Group Health care provider is not registered with the Ministry of Health as an affiliate of this group on date of service

Provider registration

Affiliated Practitioner inactive Health care provider is not actively registered with the Ministry of Health as an affiliate of this group on date of service

Provider registration

Referring laboratory is not registered with the Ministry of Health

Provider registration

Contract characteristics error

Provider registration

Practitioner Not Eligible On Service Date New Graduate bills New Patient fee (Q013) or Physician (not a new graduate) bills new Graduate-New Patient fee (Q033).

Provider registration

Master Number (MNI) Does not Meet Criteria A100 billed with a specialty code other than 00.

Provider registration

Physician Not Eligible to Claim FSC A100 billed with a speciality code other than 00 or billed by provider with any Emergency Department Alternate Funding arrangement (EDAFA) group number.

Provider registration

Not Registered for Use

Provider registration

Registration Usage Error on Service Date

Provider registration

Enrolment Type Not Eligible

Provider registration

Practitioner Criteria Not Met

Provider registration

Referring physician number is currently ineligible for referrals

Depends on the claim

APP group affiliation on service date Hospital Emergency Department is part of an alternative funding agreement

Depends on the claim

Not eligible to bill

Depends on the claim

Not Eligible For Blank HN

Depends on the claim

Invalid Blank HN Claim No HN required for FSC

Depends on the claim

Not Registered for Telemedicine

Administrative

Telemedicine Premium/Tracking Code Missing

Administrative

Telemedicine SLI Missing/Invalid The telemedicine billing is submitted with a telemedicine tracking code but the SLI code is not 'OTN' or is not present.

Administrative

Not on Health Care Connect (HCC) database-Not Eligible On HCC database but not Complex-Vulnerable On HCC database but not in 'referred to' status

Depends on the claim

Patient enrolled to billing physician but later than 3 months from the "referred to" date on HCC database-Enrolment after 3 Months

Depends on the claim

Invalid PA Service Physician Assistant (PA) Pilot claim submissions may contain one or more PA Tracking FSC's but other OHIP insured service FSCs are not allowed on the same claim.

Depends on the claim

Invalid PA Claim Physician Assistant Pilot (PA) claim submissions with the PA as the submitting physician must identify the solo billing number of the supervising physician in the "Refer Physician" field.

Depends on the claim

Not registered for PA The physician and/or referring physician fields on the PA Pilot claim submission contain billing numbers which are not affiliated to the PA Pilot group number.

Depends on the claim

PA Registration on Service Date Error

Depends on the claim

PA Affiliation Error

Depends on the claim

PA Affiliation on Service Date Error

Depends on the claim

No Initial Fee Previously Paid To ensure the smoking cessation initial discussion fee (E079) has been paid within 365 days prior to the smoking cessation counseling fee (Q042) or the smoking cessation follow up fee (K039)

Depends on the claim

Missing Health Service Number (HSN)

Administrative

Invalid HSN

Administrative

Invalid/Missing Province Code

Administrative

Service Excluded from RMBS

Administrative

Provincial code invalid for RMBS Province code of 'ON' (Ontario) or ‘PQ’ (Quebec) and not an Outaouais claim

Administrative

Invalid Provider for RMBS

Administrative

Invalid Payment Type for RMBS

Administrative

Invalid Referral Number

Administrative

Claim Header 2 Missing-RMB

Administrative

Duplicate Telemedicine Claim, Same patient

Administrative

Service not Billable for Missed/ Cancelled/Abandoned Appointment

Administrative

Service not payable underTelemedicine Program

Administrative

Non Telemedicine Claim paid for same patient

Administrative

Telemedicine Claim Paid for same patient

Administrative

Registration not in effect on Service Date

Administrative

Dental Service not eligible for Telemedicine

Administrative

Not eligible for Store Forward

Administrative

Invalid Region Code

Administrative

Error-Claim Number is less than Service Date

Administrative

Incorrect Clinic Code

Administrative

Invalid Practitioner Number

Administrative

Invalid Specialty Code: Specialty code is missing/not 2 numerics Not a valid specialty code Specialty code is 27 and provider number is not 599993 Specialty code is 90 and provider number is not 991000 Specialty code is 49, 50, 51, 52, 53, 54, 55, 70 and 71 and the health care provider number does not begin with 4 Specialty code is 56 and health care provider number does not begin with 80 or 81 Specialty code is 80 or 81 and health care provider number does not begin with 82

Administrative

Invalid Referral Number

Administrative

Patient's last name is missing/not alphabetic (A-Z) First field position is blank

Administrative

Patient's first name is missing/not alphabetic (A-Z) First field position is blank

Administrative

Patient's date of birth is missing/invalid format Month not in the range of 01-12 Not 8 numerics Day is outside acceptable range for month

Administrative

Patient sex must be '1' (male) or '2' (female)

Administrative

Unacceptable Diagnostic Code Not numeric

Diagnostic code

Payee must be 'P' (Provider) or 'S' (Patient)

Administrative

Invalid Amission/First Visit date

Administrative

Invalid Chiropractor Diagnostic Code

Diagnostic code

Unacceptable Age for Diagnostic code Service code is A007, patient is over 2 years old and diagnostic code is '916' or service code is A003 and the patient is under 16 years old and the diagnostic code is '917'

Diagnostic code

Diagnostic Code Required

Diagnostic code

Invalid Diagnostic Code

Diagnostic code

Check Number Of Services

Administrative

Invalid Hospital Number

Administrative

Invalid In-Out-Patient Indicator

Administrative

FSC/Diagnostic Code Combination Not A Benefit (NAB)

Diagnostic code

Error in Claim Header Missing any of the following: group number, health care provider number, specialty code

Administrative

Invalid Service Code Service Code and Health Care provider type mismatch

Administrative

Invalid Out-of-Province/Out-of-Country Service

Administrative

Check input criteria required for sessional billing

Administrative

Number of items exceeds the maximum (99)

Administrative

Invalid Fee Schedule Code Service code is missing Service code is not in the format ANNNA where: A is alphabetic (A-Z) NNN is numeric (001-999) A is alphabetic (A-C)

Administrative

Invalid Fee Billed Fee submitted is missing/not 6 numerics Fee submitted is not in the '000000'-'500000' ($$$$cc) range

Administrative

Invalid Number of Services Number of services is missing/not 2 numerics Number of services is not in the range '01-99'

Administrative

Fee not Divisible Fee submitted is not evenly divisible (to the cent) by the number of services

Administrative

Service Date Pre Initial Visit Physiotherapy

Administrative

Invalid location code must be blank or four numerics. If present, must be valid based on MOHLTC Residency Code Manual

Administrative

Invalid FSC-Magnetic Tape/Disk

Administrative

Invalid service location indicator hospital diagnostic service billing from a participating hospital physician/group is not of the five valid SLI codes (HDS, HED, HIP, HOP or HRP)

Administrative

Referring Laboratory Number must start with 5 (5###)

Administrative

Missing service location indicator

Administrative

Missing master number SLI code HDS, HED, HIP, HOP or HRP is included with a diagnostic service billing but a master number was not included

Administrative

Missing admission date SLI code HIP is included with a diagnostic service billing but an admission date was not included

Administrative

Missing master number and admission date assigned when a SLI code HIP is included with a diagnostic service billing but a master number and admission date were both not included

Administrative

Incorrect service location indicator assigned when a diagnostic service is billed with a master number and admission date but the SLI code is not HIP

Administrative

Service Date Invalid for SLI

Administrative

Date of service is greater than the file/batch creation date

Administrative

Invalid Dental Master Number

Administrative

OTN SLI No Longer Active

Administrative

Wrong Preventive Care Date of Service

Administrative

Header 2 and HN Present Claim Header-2 present on MRI claim submitted with Health Number in Claim Header-1

Patient information

Health Number is missing/invalid

Patient information

Health Number is Missing Health Number is not present (Payment program is HCP or WCB)

Patient information

Invalid Payment Program The payment program is missing or is not equal to HCP, RMB, WCB

Patient information

Invalid Version Code

Patient information

OHIP Number Required for Service Date

Patient information

Mixed Service Dates

Patient information

Health number and OHIP number on same claim

Patient information

Date of birth does not match the Health Number submitted

Patient information

Health Number is not registered with ministry

Patient information

OHIP number not registered with ministry for health number

Patient information

No HN Required for FSC A non-encounter service claim submitted with a Health Number

Patient information

SLI required for technical fee

Patient information

Invalid Service Date Date of Service is missing/not 8 numerics Month is not in the range 01-12 Day is outside acceptable range for month Date of Service is greater than Ministry of Health system run date

Administrative

Stale-dated Claim

Not re-billable

Stale-dated Claim Encounter

Not re-billable

Invalid SEAMO Provider Code

Administrative

Invalid Venue Type

Administrative

Invalid Clinic Number

Administrative

Invalid Healthcare Item

Administrative

Invalid In-Patient/Out-Patient Indicator

Administrative

Invalid HC Item Code Format

Administrative

Only 1 VTC allowed

Administrative

Virtual Tech Code required

Administrative

Invalid WCB Service

Administrative

Fee Schedule Code(s) used is not correct, please resubmit claim with the appropriate FSC or submit an RAI if the claim is posted on a Remittance Advice

Coding problem

Service is not a benefit of OHIP (Ontario Health Insurance Plan)

Not re-billable

Not a valid network service

Not re-billable

OHIP records show service(s) on this day claimed previously

Not re-billable

Approved

Paid per rule

OHIP records show this service rendered has been claimed previously (used on Pay Practitioner duplicate claims)

Not re-billable

OHIP records show service has been rendered by another Practitioner, Group, Lab

Not re-billable

Effective April 1, 1993 the listed benefit for this code is 0 Laboratory Medicine Services (LMS) units

Not re-billable

Service or related service allowed only once for same patient

Not re-billable

Fee Schedule Code (FSC) Billed No Evidence in Supporting Documentation Provided

Administrative

FSC Billed Included in Other Procedure

Coding problem

Specialty code restriction on Fee Schedule Code

Provider registration

Paid Per 2nd Review by Medical Advisor (MA)

Paid per rule

Not Paid Per 2nd Review by Medical Advisor (MA)

Administrative

Paid as submitted clinical records may be requested for verification purposes

Paid per rule

Paid according to the average fee for this service. Independent consideration will be given if clinical records/operative reports presented.

Administrative

Paid in accordance with the Schedule of Benefits

Paid per rule

Fee Schedule Code changed in accordance with Schedule of Benefits

Coding problem

Fee-for-service assessed by medical consultant

Administrative

Fee allowed according to appropriate item in a previous Schedule of Benefits

Paid per rule

Interim payment claim under review

Administrative

Deduction is an adjustment on an earlier account

Paid per rule

Claim under review

Administrative

This payment is an adjustment on an earlier account

Paid per rule

Claimed by another physician within group

Not re-billable

Practitioner's notification WCB claims

Administrative

Not a benefit of the Reciprocal Medical Billing Agreement

Not re-billable

Claim assessed by Assessment Officer

Administrative

Service included in approved hospital payment

Not re-billable

Reduced per Alternative Payment Program (APP) Funding Contract

Paid per rule

Elective Services Paid At 75% Of OHIP Schedule of Rates

Paid per rule

OHIP records show corresponding procedure(s) on this day claimed previously by another physician

Not re-billable

Technical fee adjustment for hospitals

Paid per rule

Not allowed in addition to health exam

Coding problem

This payment is in accordance with legislation. If you disagree with the payment, you may appeal to the General Manager

Administrative

Service Not Eligible for Payment When Delivered by Telephone

Coding problem

Paid in accordance with the OHIP Schedule of Benefits for Telephone Virtual Care Services

Paid per rule

Patient-Physician Relationship Requirements Not Met

Coding problem

Virtual Service not allowed in addition to In-Person Equivalent Service

Coding problem

In-Person Service Not Allowed in Addition to Virtual Equivalent Service

Coding problem

Limited Virtual Care Service Already Paid

Not re-billable

Comprehensive Virtual Care Service Already Paid

Not re-billable

Service Not Eligible for Payment Virtually

Coding problem

Allowed as repeat/limited consultation/midwife-requested emergency assessment

Coding problem

Allowed at re-assessment fee

Coding problem

Allowed at minor assessment fee

Coding problem

Consultation not allowed with this service-paid as assessment

Coding problem

Allowed as multiple systems assessment

Coding problem

Allowed as Type 2 admission assessment

Coding problem

An admission assessment (C003A) or general re-assessment (C004A) may not be claimed by any physician within 30 days following a pre- dental/pre-operative assessment

Not re-billable

Payment reduced to geriatric consultation fee-maximum number of comprehensive geriatric consultations has been reached

Not re-billable

Allowed as in-patient interim admission orders-initial assessment already claimed by other physician

Coding problem

Allowed as repeat procedure-initial procedure previously claimed

Coding problem

Additional procedures allowed at 50%

Paid per rule

Not allowed in addition to visit fee

Coding problem

Procedure allowed at 50% with visit

Paid per rule

Procedure already allowed-visit fee adjusted

Not re-billable

Limit of payment for this procedure reached

Not re-billable

Not allowed in addition to other procedure

Coding problem

Allowed with specific procedures only

Coding problem

Not allowed to a hospital department

Coding problem

Maximum for this procedure reached paid as repeat/chronic procedure

Not re-billable

Other dialysis procedure already paid

Not re-billable

Procedure paid previously not allowed in addition to this procedure- fee adjusted to pay the difference

Coding problem

Not allowed as diagnostic code is unrelated to original eye exam

Diagnostic code

Lab tests already paid-visit fee adjusted

Not re-billable

Corresponding fee code was not billed or paid at zero

Coding problem

Diagnostic/Miscellaneous services for hospital patients are not payable on a fee-for-service basis in the Hospital Global budget.

Not re-billable

Ventilatory support allowed with Haemodialysis

Paid per rule

Allowed as laboratory tests in private office

Paid per rule

Paid/disallowed in accordance with MOH policy regarding an Emergency Department Equivalent

Paid per rule

Allowed as pudenal block in addition to procedure-as per stated OHIP policy

Paid per rule

Procedure paid previously allowed at 50% in addition to this procedure-fee adjusted to pay the difference

Coding problem

Self-Referred Diagnostic Services Payable at 50%

Paid per rule

Not allowed-mutually exclusive code billed

Coding problem

In-patient technical fee not allowed

Coding problem

Service is included in Monthly Management Fee for Long-Term Care (LTC) patients

Not re-billable

Procedure paid previously not allowed in addition to monthly management. For long-term care patients-fee adjusted to pay the difference.

Not re-billable

Diagnostic code not eligible with Fee Schedule Code

Diagnostic code

Service date prior to start of eligibility

Patient information

Incorrect version code for service date

Patient information

Version Code not on File for HN (Health Number)

Patient information

Service date after the eligibility termination date

Patient information

Service date not within an eligible period

Patient information

Service Date after Eligibility End Date Eligibility Terminated as MOH Records Indicate Patient Deceased

Patient information

Service Date after Eligibility End Date Eligibility Terminated Due to no Response to Notice to Register

Patient information

Service date is not within an eligible period Services provided on or after the 20th of this month will not be paid unless eligibility status changes

Patient information

Coding added/changed in accordance with Schedule of Benefits

Coding problem

Assessment Allowed at Full Fee for Patient Proceeding to Hospital

Paid per rule

Incorrect version code-services provided on or after the 20th of this month will not be paid unless the current version code is provided

Patient information

Network billing not allowed

Administrative

This payment is an adjustment of an earlier account due to provider registration update

Provider registration

Check health card for current version code

Patient information

Additional fractures/dislocations allowed at 85%

Paid per rule

Allowed in accordance with transferred care

Paid per rule

Previous attempted reductions (open or closed) allowed at 85%

Paid per rule

Two weeks aftercare included in fracture fee

Not re-billable

Allowed as Minor/Partial Assessment

Coding problem

Additional payment for the claim shown

Paid per rule

Other critical/comprehensive care already paid

Not re-billable

Coverage lapsed-bill patient for future claims

Patient information

Admission assessment or Emergency department assessment already paid

Not re-billable

Allowed as subsequent visit initial visit previously claimed

Coding problem

Maximum fee allowed per week after 5th week

Not re-billable

Maximum fee allowed per week after 6th week to pediatricians

Not re-billable

Maximum fee allowed per month after the 13th week

Not re-billable

Allowed as supportive or concurrent care

Coding problem

Allowed as chronic care

Coding problem

Hospital number and/or admission date required for in-hospital service

Administrative

Concurrent care already claimed by another doctor

Not re-billable

Admission assessment claimed by another physician-hospital visit fee applied

Coding problem

Subsequent Visit Already Paid Same Day

Not re-billable

Concurrent or supportive care already claimed in period

Not re-billable

Invalid master number used on date of service

Provider registration

Service is globally funded

Provider registration

Fee Schedule Code is not on the IHF (Independent Health Facility) licence profile for the date specified

Provider registration

Records show service has been rendered by another Practitioner, Group or IHF

Not re-billable

Service is globally funded and Fee Schedule Code is not on IHF licence profile

Provider registration

Premium not applicable

Coding problem

Claim date does not match patient enrolment date

Provider registration

Confirmation not received

Provider registration

Payment not applicable/expired

Provider registration

Service Date is Before the Effective Date of OHIP Coverage

Patient information

Service Date is After the Termination of Coverage Date

Patient information

Approved for stale dated processing

Administrative

Coverage Applied For; Premiums Not Yet Paid

Patient information

Claim submitted three months after service date

Not re-billable

Coverage Not In Effect; Services Provided On Or After The 20th Of This Month Will Not Be Paid Unless Subscriber Takes Corrective Action

Patient information

Coverage Reinstated. Submit Claims Routinely

Patient information

This service paid to another laboratory

Not re-billable

Not allowed to medical Laboratory Director

Coding problem

Not allowed in addition to other laboratory procedure(s)

Coding problem

Not allowed to attending physicians

Coding problem

Not allowed in addition to other procedure paid to another laboratory

Coding problem

Procedure paid previously to another laboratory, not allowed in addition this procedure-fee adjusted to pay the difference

Coding problem

Not allowed-referred specimen

Coding problem

Not to be claimed with prenatal/fetal assessment

Coding problem

Laboratory services for hospital in-patients or out-patients are not payable on a fee-for-service basis-included in the hospital global budget

Not re-billable

Lab service is funded by special Lab Agreement

Paid per rule

Paid in accordance to special Lab Agreement

Paid per rule

Maximum fee allowed or maximum number of service has been reached same/any provider

Not re-billable

Maximum allowance for radiographic examination(s) by one or more practitioners

Not re-billable

Maximum fee allowed for prenatal care

Not re-billable

Maximum fee allowed for these services by one or more practitioners has been reached

Not re-billable

Monthly maximum has been reached

Not re-billable

Maximum fee allowed for special visit premium-additional patient seen

Not re-billable

Maximum number of sessions has been reached

Not re-billable

Maximum number of case conferences has been reached in a 12 month period

Not re-billable

Daily maximum has been exceeded

Not re-billable

Maximum number of e-assessments paid

Not re-billable

Claim does not meet requirements of the Physician Schedule of Benefits

Not re-billable

Maximum number of occipital nerve block sessions has been reached

Not re-billable

Maximum number of Optical Coherence Tomography (OCT) services has been reached

Not re-billable

Minimum service requirements have not been met

Not re-billable

Maximum allowed for sleep studies in a specific period by one or more physicians has been reached

Not re-billable

Maximum Units Exceeded

Not re-billable

Maximum Number of Weeks has elapsed since payment of initial service

Not re-billable

Maximum of 2 arthroscopy "R" codes with E595 has been reached

Not re-billable

Yearly maximum has been exceeded

Not re-billable

Fee for obstetric care apportioned

Paid per rule

Previous prenatal care already claimed

Not re-billable

Previous prenatal care already claimed by another doctor

Not re-billable

Office visits relating to pregnancy and claimed prior to delivery included in obstetric fee

Not re-billable

Not allowed in addition to delivery

Coding problem

Medical induction/stimulation of labour allowed once per pregnancy

Not re-billable

Allowed as subsequent prenatal visit-initial prenatal visit already claimed

Coding problem

Allowed once per pregnancy

Not re-billable

Not allowed in addition to post-natal care

Coding problem

Maximum fee allowed for low birth weight care

Not re-billable

Maximum fee allowed for newborn care

Not re-billable

Fee for newborn care/low birth weight care is not billable with neonatal intensive care

Coding problem

Over-age for paediatric rates of payment

Coding problem

Over-age for well-baby care

Coding problem

Health Care Connect greater than 3 months

Administrative

Complex New patient

Coding problem

Minimum roster size not met

Provider registration

No fee allowed for treatment of immediate family

Not re-billable

Lab not licensed to perform this test on date of service

Provider registration

Only one health exam allowed in a twelve-month period

Not re-billable

10 Well Baby Visits Allowed Up To Two Years Of Age

Not re-billable

One Well Child Exam (Age 2-5 Years) Allowed Within A12 Month Period

Not re-billable

Duplicate, paid in Reciprocal Medical Billing System (RMBS)

Not re-billable

Bilateral surgery, one stage, allowed at 85% higher than unilateral

Paid per rule

Bilateral surgery, two stage, allowed at 85% higher than unilateral

Paid per rule

Second surgical procedure allowed at 85%

Paid per rule

Procedure fee reduced when paid with related surgery or anaesthetic

Paid per rule

Not allowed in addition to major surgical fee

Coding problem

Allowed as subsequent procedure-initial procedure previously claimed

Coding problem

Normal pre-operative and post-operative care included in surgical fee

Not re-billable

Initial procedure not found

Coding problem

Surgical procedure allowed at consultation fee

Coding problem

Normal pre-operative visit included in surgical fee-visit fee previously paid-surgical fee adjusted

Not re-billable

Not allowed, major pre-operative visit already claimed

Not re-billable

Not allowed, Team/Assist Fee already claimed

Not re-billable

Major pre-operative visit previously paid and admission assessment previously paid-surgery fee reduced by the admission assessment

Not re-billable

Most Responsible Physician (MRP) visit not allowed during post- operative period-surgical fee adjusted

Not re-billable

Multiple Surgical Anaesthesia. Documentation of Separate Surgeries Same Day/Same Patient Required

Administrative

MRP visit not allowed during post-operative period-fee reduced to subsequent visit fee

Not re-billable

Intensive Care Unit per diem code paid to another physician-MRP subsequent visit reduced to subsequent visit

Not re-billable

ICU Per Diem code Paid To Another Physician, MRP Premium Not Allowed

Not re-billable

Fee allowed according to surgery claim

Paid per rule

Allowed as repeat assessment-initial assessment previously claimed

Coding problem

Allowed as extra patient seen in the home

Coding problem

Not allowed in addition to procedural fee

Coding problem

Date of service was not a Saturday, Sunday or statutory holiday

Coding problem

Only one major oculo-visual examination allowed in a 12-month period for under 19 or over 65 with medical condition; 1 in 18 month period for over 65 withouut medical condition

Not re-billable

Allowed as minor assessment-initial assessment already claimed

Coding problem

Allowed at medical/specific re-assessment fee

Coding problem

This service paid at lower fee as per stated OHIP policy

Paid per rule

Only one initial office visit allowed within a twelve-month period

Not re-billable

Procedure fee reduced-consultation/visit fees not allowed in addition

Coding problem

Additional Oculo-Visual Assessment (OVA) is allowed once within the second year for patients aged 20-64, following a periodic OVA

Coding problem

Procedure Paid Previously Not Allowed In Addition To Visit Fee. Fee Adjusted To Pay The Difference

Coding problem

Only one geriatric general assessment premium per patient per 12- month period

Not re-billable

Oculo-visual minor assessment is only allowed within eligibility period after a major oculo-visual examination

Coding problem

Allowed as major oculo-visual examination for seniors with medical conditions

Coding problem

Allowed with special visit only

Coding problem

Visit reduced premium not applicable

Coding problem

Date of service was a Saturday, Sunday or statutory holiday

Coding problem

Complexity premium not applicable to visit fee

Coding problem

Warning: Service date is older than 3 months

Administrative

Warning:-service location indicator code missing

Administrative

Gastrointestinal (G.I.) tract includes cine and video tape

Not re-billable

Gastrointestinal (G.I.) tract includes survey film of abdomen

Not re-billable

Only one Bone Mineral Density (BMD) allowed within a 36 month period for a low risk patient

Not re-billable

Only one Bone Mineral Density (BMD) allowed within a 12 month period for a high risk patient

Not re-billable

Only one Bone Mineral Density (BMD) allowed within a 60 month period for a low risk patient

Not re-billable