- Schedule of Benefits
- Your Billing Process
- Billing Corner Queries & Complaints
- IFHP - Billing Sans OHIP
Schedule of Benefits (SOB)
MOHLTC OHIP Schedule of Benefits and Fees (Effective March 1, 2016 ...as most recently amended Dec.22/15): Download accessible via the MOHLTC website.
UPDATED: The excerpts below now reflect the non-negotiated, government imposed 1.3% fee reduction that became effective after October 1st 2015 and any subsequent amendments up until Dec.22/15.
GENERAL SURGERY CODES: Selected excerpts from SOB as of Dec.22, 2015 - effective March 1, 2016
- Consultations & Visits - Download PDF
- Most Responsible Physician (MRP) - Download PDF
- Counselling - Download PDF
- Travel Premiums - Download PDF
- Assistants Fees - Download PDF
- After-Hours Premiums - Download PDF
- Upper Endoscopy - Download PDF
- Colonoscopy & Sigmoidoscopy - Download PDF
- Stomach - Download PDF
- Colorectal - Download PDF
- Hernia & Abdominal Wall - Download PDF
- Hepatobiliary - Download PDF
- Breast - Download PDF
- Skin & Subcutaneous Tissue - Download PDF
- Appendix - Download PDF
- Endocrine - Download PDF
- Vascular - Download PDF
- Thoracic - Download PDF
GENERAL SURGERY CODES: Miscellaneous excerpts from SOB
- Morbid Obesity Premium - Download PDF
- Trauma Premium - Download PDF
- Tedious Adhesions Premium - Download PDF
- Nerve Blocks - Download PDF
- TPN Fee - Download PDF
- Varicose Veins - Download PDF
- ICU Visit Premium - Download PDF
- Home Care Forms & Advice - Download PDF
- Physician Telephone Consult - Download PDF
- Criticall (2015-16)- Download PDF
- Multidisciplinary Cancer Conference (2015-16)- Download PDF
- Necrotizing Faciitis (2015-16) - Download PDF
FULL SECTIONS FROM THE SCHEDULE OF BENEFITS
- Section GP: General Preamble - Download PDF
- Section A: Consultations & Visits - Download PDF
- Section J: Diagnostic and Therapeutic Procedures - Download PDF
- Section SP: Surgical Preamble - Download PDF
- Section M: Integumentary System - Download PDF
- Section N: Musculoskeletal System (2016) - Download PDF
- Section R: Haematic and Lymphatic Surgical Procedures - Download PDF
- Section S: Digestive - Download PDF
- Section T: Urogenital & Urinary - Download PDF
- Section U: Male Genital - Download PDF
- Section V: Female Genital - Download PDF
- Section W: Endocrine - Download PDF
- Critical Care - Download PDF
- SOB Numeric Index - Download PDF
- Table of Contents - Download
GENERAL SURGERY CODES: OAGS Billing Summaries
|Colonoscopy Procedure Codes||Diagnostic Code|
|Z491 - FU incomplete polypectomy, large sessile polyp
• Or piecemeal or high grade dysplasia
• Payable only within 6 months
|Z492 - 5 year FU of a normal colonoscopy
• Payable every 5 years after Z499
|Z493 - 10 year FU of a normal colonoscopy
• Payable every 10 years after Z497,Z555
|Z494 - Very high risk screening - HNPCC, FAP, IBD >10 yrs
• Payable within “clinical practice guidelines”(q 1-2yr)
|Z495 - Repeat due to poor prep/ incomplete
• No interval limit
|Z496 - Symptomatic
• No interval limit
|Z497 - FU+FOBT, +DCBE, +sigmoidoscopy, +CT
• Confirmatory - no interval limit
|Z498 - Polyp Surveillance Standard Intervals 3 or 5 years
• 5 yrs if 1-2 tubular adenoma
• 3 yrs if 3+TA, >1cm, villous, any HGD, or Rt. SSA
• <3yrs if >10 adenomas
• use for colon cancer follow-up at 1, 3, 5 yr intervals
|Z499 - Family History + first scope
• 1st degree or two 2nd degree relatives at 40yrs+ (or 10 yrs
younger than earliest age of relative's diagnosis)
|Z555 - Average Risk Screening
• Payable at 10-year interval
Your Billing Process(Scroll to bottom for problem-solving contacts.)
- Billing claims are usually submitted by Electronic Data Transfer (EDT) to your local MOHLTC Claims Services Branch.
- Cut-off for submissions is the 18th of each month or next business day if it falls on the weekend (claims received after the 18th may also be processed and included in the same Remittance Advice, not necessarily in the same month)
- Providers must submit claims within 6 months of the date of service (claims submitted beyond this time frame are considered stale-dated and will be rejected to the Error Report)
- If you feel a complicated claim is going to require further documentation, make sure to submit/fax it on the same day as the EDT. Be sure to make a paper trail and get confirmation that they received it. Email confirmation is preferred, but if you call, make note of the time, date and contact person in a journal.
- Cases with multiple procedure codes and duplicate billings are automatically forwarded to a Claims Assessor (other criteria such as billing history may also be used) and will likely be rejected; you'll only be asked to be resubmit the claim with the manual documentation. Save time and delay, and do it the first time!
- Majority of billings are initially assessed through a computer
- Approximately 80% of billings are immediately approved and paid out
- Approximately 20% of billings are not system assessed and are forwarded to Claims Assessors for assessment
- Paid claims will appear on the Remittance Advice (RA)
- Unpaid/rejected claims will appear onthe Claims Error Report or the Remittance Advice with an explanatory code
- Rejected claims appearing on the Claims Error Report MUST BE RESUBMITTED, as they are deleted from the system
- IMPORTANT NOTE: Inquiries regarding overpaid or underpaid claims on the Remittance Advice must be made in writing using the Remittance Advice Inquiry Form. Do not resubmit the claim.
- Claims under review by a Claims Assessor may require further documentation by the physician.
- Fax this documentation to the Ministry office where the physician claims services are performed. Ensure that your billing number is clearly labeled at the top of EACH PAGE of your documentation being faxed. ALSO, remember to flag the claim using your billing software to indicate to the Ministry that special attention is required for that particular claim. Phone/email your local Ministry office if uncertain.
- Once these manual documents are received, your claim is then escalated to an Assessment Officer for further review.
- If the claim and documentation is still too complex or convoluted, it will be further escalated to a Medical Advisor. Once it's been assessed this time, it will appear on the provider's monthly Remittance Advice (RA) either as full, partial or denied payment.
- If the claim has been partially paid or completely denied, the surgeon/provider may appeal this by completing what is called a Remittance Advice Inquiry (RAI) (form#1). This needs to be accompanied with a letter, a note and any other additional documentation which may be of benefit.
- NOTE: Questions to the Medical Advisor should be IN WRITING ONLY. KEEP ALL CORRESPONDENCE for future reference.
- If this additional letter/document supports your appealed claim, then the claim will be adjusted.
- If the Assessment Officer or Medical Advisor stand by their initial rejection, then a response will be sent to the provider/surgeon with an explanation.
- If the surgeon still does not agree, you can appeal one final time with another Remittance Advice Inquiry (RAI) (form#2). This must be accompanied with a formal letter. At this point, it will be escalated a final time to be reviewed/discussed by a panel of three Medical Advisors. All 3 must be in agreement on the assessment. If one of the three advisors does not agree, then the provider's claim is adjusted automatically by default.
- Time Frame: As a rule, it should take about 1 month for each stage - 3 months maximum for the entire process IF you've been diligent in submitting all documentation promptly.
- Stale Billing: This refers to a claim which was not submitted correctly within 6 months of the performance of the procedure. It pertains only to the initial billing and the first response to the Claims Assessor. (After the first response to the Claims Assessor, the 6 month stale billing rule should no longer apply and payment should be made out beyond the 6 months by default, as long as you've complied to their requests in a timely manner.)
- IMPORTANT NOTE: Each physician is responsible for all claims submitted and paid in conjunction with his/her OHIP billing number. So, even if you have a 3rd party submitting your billing, you are still liable for the consequences and fraudulent claims which could jeopardize your license. Be aware of what is submitted under your name and billing number. As such, the MOHLTC recommends that physicians promptly reconcile all claims by reviewing their monthly Remittance Advice and Error Report.
- COMMON ERRORS RESULTING IN NON-PAYMENT: a) missing/illegible 6-digit billing number, clinic's 4-digit ID number, patient's health card number/info, b) documents sent to the wrong district office, or c) requested documentation is not sent along with the submitted/resubmitted claim.
- MOHLTC/OHIP Billing Claims Recommendations: •Contact patients for updated information, • Perform a monthly reconciliation of your Remittance Advice and Error Report, • Keep copies of the Remittance Advice, • Diligently follow up all underpaid/overpaid claims, • Retain all Error Reports until claims are paid, • Make corrections and re-submit claims ASAP, • Ensure new billing staff are properly trained.
Sources: MOHLTC Health Services Branch/Claims Services Branch (OAGS AGM, 2014), OAGS Billing Corner (Issue #36, 2014).
Billing Corner Queries
OAGS and Section on General Surgery members are invited to submit your billing queries to the OAGS/Section Tariff Committees: email@example.com . We also welcome suggestions for the Billing Corner newsletter column and interstitials during our fall annual meeting.
MOHLTC/OHIP Billing Claims Services Branches
- Oshawa (incl. Ottawa & London) - 1-855-250-3696 or 905-576-2870
- Toronto (incl. Sudbury & Thunder Bay) - 1-855-645-1282 or 416-314-7770
- Hamilton (incl. Mississauga & Kingston) - 1-888-630-8066 or 905-521-7100 (or -7547)
- General Claims Office - 1-800-262-6524
- Websites: www.health.gov.on.ca / MOHLTC-OHIP / OHIP Claims Offices
STILL HAVING PROBLEMS?
- Contact the OAGS Tariff Committee:
Outline your issues in an email to our OAGS office "Attn. Tariff Committee": firstname.lastname@example.org .
- Have a Complaint about your MOHLTC/OHIP Health Claims Services Branch or Your Stale-dated Claim?
This Ministry website provides a contact listing for the central Health Services Provider Facility Payment Unit. There are several fee-for-service medical advisors who can assist you. Call initially, but all communications should be in writing (and/or logged).
MOHLTC Health Services Branch & Medical Advisory Contacts: www.infogo.gov.on.ca
- OMA Economics Department
The OMA Economics Dept can also offer billing advisory: email@example.com
Sources: MOHLTC Health Services Branch/Claims Services Branch (OAGS AGM, 2014), OAGS Billing Corner (Issue #36, 2014).
Interim Federal Health Program (IFHP)
The Interim Federal Health Program, funded by Citizenship and Immigration Canada (CIC), provides limited, temporary coverage of health-care costs to protected persons, including resettled refugees, refugee claimants, certain persons detained under the Immigration and Refugee Protection Act and other specified groups, who are not eligible for provincial or territorial health insurance plans and where a claim cannot be made under private health insurance. The program helps protect public health and public safety, and offers access to urgent or essential health services and products to some of the eligible groups above. The IFHP primarily offers five types of coverage: health care coverage, expanded health care coverage, public health or public safety health care coverage, coverage for the Immigration Medical Examinations, and coverage for detainees. The IFHP provides coverage to eligible beneficiaries, via a contracted claims administrator, through a network of registered health-care providers across Canada. Health-care providers are reimbursed directly for covered services rendered to eligible beneficiaries. - IFHP Program / Medavie Blue Cross
Syrian Refugee Relocation Aid - As of December 3, 2015...
"The OMA is deeply concerned for those impacted by the incredible disruption in war-torn Syria....The OMA ...encourages members to participate in the Syrian relief effort and will update members as the needs of the new refugee communities become known. For those interested in providing health care to refugees coming to your community, the memo from Minister Hoskins (https://www.oma.org/Resources/Documents/HoskinsMemoSyrianRefugees20151201.pdf) outlines the province’s plans to ensure health care delivery for those refugees resettling in the province. The federal government will be covering the costs associated with care for the first year in Canada. Medavie Blue Cross maintains a list of registered providers at http://www.ifhp-pfsi.ca so that private sponsors, clients and others stakeholders can readily identify providers in their community...." - Ontario Medical Association
- Medavie Blue Cross - website
- Gov't of Canada IFHP Program - Information for Health Care Professionals - website
- List of IFHP Providers in Ontario- download
Become a Medavie Blue Cross Registered Provider
Determine Client Eligibility
To ensure reimbursement for your services or products by the IFHP, you must verify that a patient is eligible for IFHP with Medavie Blue Cross before providing a service or product each time you see that patient, as a person may cease to be eligible or have their coverage changed at any time.
Before providing a service or product, you can quickly and easily verify your patient’s IFHP coverage:
•Call Medavie Blue Cross at 1-888-614-1880 (08:30 to 16:30 in each Canadian zone); or,
•Log into the secure section of the provider web portal.
•Use these resources to help you navigate the portal and provide services to your patient:
◦Quick Reference Guide – Verify Patient Coverage (PDF, 242 KB)Note that it takes at least two business days for coverage to be activated in Medavie Blue Cross’ system after it is issued by CIC.
◦IFHP Information Handbook for Health Care Professionals (PDF, 9.4 MB)
Submit a claim and receive payment
You must not charge beneficiaries for services or products covered under the IFHP. You must directly bill the IFHP through Medavie Blue Cross. Claims can be submitted electronically via the provider web portal, by mail or can be faxed to 506-867-3841.
Before you provide treatment:
Ask patients if they are eligible for any other private health insurance program or plan that covers the service or product. If the patient has another plan or program, you cannot be reimbursed by the IFHP. Find out more about IFHP coverage types. See the Medavie Blue Cross Provider Portal for benefit grids for each coverage type.
After you provide treatment:
You must ask the beneficiary to sign the claim form before you submit it to Medavie Blue Cross. Submit a claim to Medavie Blue Cross:
•Online: Submit your claim through the Secure Provider Web portal
•By mail: Interim Federal Health Program Medavie Blue Cross 644 Main St. PO Box 6000 Moncton, NB E1C 0P9
•By fax: 506-867-3841
Consult the following Medavie Blue Cross guides for more information on how to submit a claim and receive payment: •IFHP Information Handbook for Health Care Professionals (PDF, 9.4 MB)
•Quick Reference Guide – Verify Patient Coverage (PDF, 242 KB)
•Secure Web Portal and Electronic Claims Submissions Service Guide (October 2011) (PDF, 125 KB)
•Electronic Dental Claims Quick Reference Guide (PDF, 110 KB)
•Claims Procedures for Point of Sale (POS) Claims Transmissions (PDF, 73 KB)
Resource: Government of Canada Citizen and Immigration - IFHP - website