Claims Submission Ontario Health Insurance Program
Resource Manual for Physicians
 
4.4   Submission of Claims (Continued)

The following services are excluded from RMB (but are not necessarily OHIP benefits) and should be billed directly to the non-resident patient :

  • Surgery for alteration of appearance (cosmetic surgery);
  • Sex reassignment surgery;
  • Surgery for reversal of sterilization;
  • Therapeutic abortion;
  • Routine periodic health examinations including routine eye examinations;
  • In-vitro fertilization, artificial insemination;
  • Lithotripsy for gall bladder stones;
  • Treatment of port wine stains on other than the face or neck, regardless of the mode of treatment;
  • Acupuncture, acupressure, transcutaneous electro-nerve stimulation (TENS), moxibustion, biofeedback, hypnotherapy;
  • Services to persons covered by other agencies (i.e., RCMP, Armed Forces, Workplace Safety and Insurance Board, Department of Veterans' Affairs, Correctional Services of Canada [Federal penitentiaries] );
  • Services requested by a third party;
  • Team conference(s);
  • Genetic screening and other genetic investigation, including DNA probes;
  • Procedures still in the experimental/developmental phase;
  • Anaesthetic services and surgical assistant services associated with all of the above;
  • Services required by the Ministry of Community and Social Services and the Ministry of Attorney General or the Solicitor General.
Note :   The patient may be eligible for direct reimbursement by his or her own provincial plan.

Coding Requirements

Fee Schedule Codes are located in the ministry Schedule of Benefits.   In addition, the following information will assist with the submission of claims :

  • Diagnostic Codes;
  • Services Requiring Diagnostic Codes.

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