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Ontario Health Insurance Plan

OHIP Bulletins


Primary Health Care Services InfoBulletins

To:  Physicians, Nurse Practitioners, Hospitals, Clinics and Laboratories

Published by:  Health Services Branchh

Date Issued:  November 8, 2016

Bulletin Number:  11162

Re:  OHIP Claims for Fertility Services and the Ontario Fertility Program

PDF Version Portable Document Format


Background

This bulletin provides further information regarding OHIP claims for fertility services and funding for fertility services under Ontario's new Fertility Program.

Effective December 21, 2015, Artificial Insemination (AI), including Intra-Uterine Insemination (IUI), and In Vitro Fertilization (IVF) were removed from the Schedule of Benefits for Physician Services (the Schedule) as insured services, and Regulation 552 under the Health Insurance Act (HIA) was amended to include IVF and AI/IUI as excluded services under section 24(1). Section 24(2) of Regulation 552 deems physician, laboratory, and hospital services in support of AI/IUI and IVF to also be uninsured.

Fertility Preservation (FP) – egg or sperm freezing – and all supporting services remain uninsured.

Ontario's new Fertility Program, launched December 21, 2015, funds AI/IUI, IVF, and FP as uninsured services outside of OHIP through Transfer Payment Agreements (TPA) with participating fertility clinics across the province.

Please see INFOBulletins #4662 and #4663 for the original announcement about changes to fertility services under OHIP and the new Fertility Program.

OHIP Claims for Fertility Services

What fertility services are no longer OHIP insured?

All physician, hospital and laboratory services provided in support of AI/IUI, IVF, or FP treatment cycles are not insured, and claims for these services are not payable by OHIP and should not be submitted to OHIP for payment. For greater clarity, any physician service listed in the Schedule in support of AI/IUI, IVF, or FP treatment cycles is not insured and not payable by OHIP. Examples include point of care testing and ultrasounds.

This applies to services rendered as part of cycles funded under the Fertility Program as well as those cycles paid for privately by patients.

For illustration purposes only, the following services listed in the table below are uninsured when provided in support AI/IUI, IVF, or FP:

Code Service
Laboratory Medicine
G015/L315 FSH (pituitary gonadotrophins)
G016/L341 TSH (thyroid stimulating hormone)
G017/L332 Prolactin
G018/L310 Estradiol
G019/L328 LH (luteinizing hormone)
G020/L331 Progesterone
G021/L318 HCG (human chorionic gonadotrophins) quantitative
Diagnostic Ultrasound
J162 Pelvis – complete
J138 Intracavitary ultrasound (e.g. transrectal, transvaginal)
J165 Transvaginal sonohysterography – may include saline or other intracavitary contrast media except Echovist
J476 Transvaginal sonohysterography – including Echovist contrast media
J163 Pelvis – limited study
J161 Intracavitary ultrasound-limited
J164 Follicle monitoring studies
Gynaecology
G334 Telephone supervisory fee for ovulation induction with human menopausal gonadotropins or gonadotropin-releasing hormone
A203 Specific assessment
A204 Partial assessment

Please note that this list is not exhaustive. All services are uninsured if performed as part of AI/IUI, IVF, or FP treatment cycles. This includes pre-operative consultation, counselling, endometrial sampling, special visit premiums, urinalysis, venipuncture, injections, etc.

Claims for these services submitted to OHIP are being monitored closely.

What fertility services remain insured?

Services to diagnose infertility and to support natural conception (such as cycle monitoring for timed intercourse) remain insured services and claims may be payable by OHIP.

What fertility services are paid outside of OHIP?

Services performed in support of AI/IUI, IVF, and FP, and claims for these services are not payable by OHIP under any circumstance. However, if the AI/IUI, IVF, or FP cycle is funded by the Fertility Program, then payments for the supporting services are included when specified as part of the bundled payments under the Fertility Program.

The specific funded services under the Fertility Program are listed in the TPA with the participating clinic and payments are made directly by the ministry to the participating clinic.

Patients receiving a funded AI/IUI, IVF, or FP cycle covered under the Fertility Program cannot be charged for any of the funded services.

Examples of Billing Scenarios

Example 1:
Patient A is undergoing a funded IVF cycle as part of the Fertility Program. As part of the cycle monitoring leading up to the oocyte retrieval, Doctor B performs ultrasound imaging to count and measure ovarian follicles. Blood tests for tracking various hormone levels are also performed.

Can the physician submit a claim to OHIP for the ultrasounds and blood work testing that are part of Patient A's IVF cycle monitoring?

No. Any ultrasounds and blood work done to support a patient's IVF cycle are not insured and are not payable by OHIP. Because this IVF cycle was a part of the Fertility Program, payment for the ultrasounds and blood work is included as part of the bundled payment made to the participating clinic. Participating clinics are responsible for remunerating physicians for services rendered, and the patient cannot be charged for these services.

Example 2:
Patient C is waiting to begin a funded IVF cycle with the Fertility Program. While she is waiting, Patient C proceeds with cycle monitoring to support natural conception through timed intercourse. Doctor D performs ultrasounds and blood work as part of the cycle monitoring.

Can the physician submit a claim to OHIP for the cycle monitoring related to natural conception?

Yes. OHIP insures a number of physician and laboratory services delivered to support natural conception. Ultrasounds and blood work as part of cycle monitoring in support of natural cycles can be submitted in a claim to OHIP for payment.

Example 3:
Patient E is in the middle of her one funded IVF cycle under the Fertility Program, and she begins cycle monitoring for her first frozen embryo transfer which will be performed at a participating fertility clinic. The cycle monitoring takes place at Doctor F's office, rather than at the clinic. Doctor F performs a baseline assessment involving blood work and an ultrasound. Patient E's cycle is then monitored with more blood tests and ultrasounds to ensure her hormone levels are optimal and her endometrium is ready for the frozen embryo transfer.

Can the physician submit a claim to OHIP for the blood tests and ultrasounds performed as part of cycle monitoring for the frozen embryo transfer?

No. Any services rendered in support of IVF are uninsured. Claims for any services to support frozen embryo transfers, such as blood work and ultrasounds, cannot be submitted to OHIP. This is true regardless of whether the services are rendered at a funded clinic or at an alternate site such as a physician's office. Because this IVF cycle was funded by the Fertility Program, all cycle monitoring for frozen embryo transfers, including baseline and subsequent blood work and ultrasounds, is included in the bundled payment made to the participating clinic. Participating clinics are responsible for remunerating physicians for services rendered, and the patient cannot be charged for these services.

Example 4:
Patient G has been advised to proceed with an endometrial sampling (womb scratching) to improve the chances of implantation for her funded fresh embryo transfer. The endometrial sampling is performed by her physician Doctor H on the day of her transfer.

Can the physician submit a claim to OHIP for a partial assessment (A204) and for the endometrial sampling procedure (Z770)?

No. As IVF is no longer an insured service, any procedure provided in support IVF is also not insured and not payable by OHIP. As this is a funded IVF cycle under the Fertility Program, the endometrial sampling procedure and assessment would be covered under the bundled IVF payment to the participating clinic. Participating clinics are responsible for remunerating physicians for services rendered, and the patient cannot be charged for these services.

Example 5:
During cycle monitoring for a funded AI/IUI cycle under the Fertility Program, Patient I has blood drawn for hormone analysis and has a pelvic ultrasound to measure the size of the ovarian follicles and the thickness of the endometrial lining. Prior to the insemination, the Doctor J cancels Patient I's AI/IUI cycle based on these test results.

Can the physician submit a claim to OHIP for the follicle monitoring, blood work and ultrasounds?

No. As AI/IUI is no longer an OHIP-insured service, any procedure done to support AI/IUI is also not insured and physicians cannot submit claims to OHIP for these services.

As this is a funded AI/IUI cycle under the Fertility Program, certain blood tests and ultrasounds are included in the bundled IVF payment to the participating clinic. Participating clinics are responsible for remunerating physicians for services rendered, and the patient cannot be charged for these services.

Example 6:
Doctor K administers a human chorionic gonadotropin (HCG) "trigger" shot to Patient L to induce maturation of the oocytes prior to retrieval for use in IVF.

Can the physician submit a claim to OHIP for the HCG injection given to the patient?

No. Any injection given to a patient for the purposes of an IVF cycle is uninsured and claims for this service cannot be submitted to OHIP.

Example 7:
As part of her IVF treatment funded by the Fertility Program, Patient M has a quantitative beta HCG blood test to monitor for a possible pregnancy following her embryo transfer.

Can the physician submit a claim to OHIP for the first BHCG test following the embryo transfer?

No. The first BHCG following IVF (or AI/IUI) is considered part of the funded cycle and therefore is covered under the bundled IVF payment to the participating clinic. Participating clinics are responsible for remunerating physicians for services rendered, and the patient cannot be charged for this service.

However, services not rendered in support of the IVF (or AI/IUI) cycle but instead rendered in support of a pregnancy or a possible high risk early pregnancy remain OHIP-insured. For example, in the case of serial BHCG tests, these tests would be insured under OHIP provided they are medically necessary for the patient's individual clinical circumstances. Examples of such circumstances include monitoring for a miscarriage or ectopic pregnancy. The physician could submit a claim to OHIP for these services.

Example 8:
Patient N is paying privately for her IVF cycle. During the cycle monitoring, Doctor O performs the ultrasounds and later discusses the results with Patient N.

Can the physician submit claims to OHIP for the ultrasounds and consultation?

No. IVF is no longer an insured service and, therefore, claims for these services cannot be submitted to OHIP. As the patient is paying privately for her IVF cycle, these services can be charged to the patient.

Example 9:
Patient O will be undergoing surgical sperm aspiration as part of his partner's funded IVF cycle.

Can the physician submit a claim for an assessment (A203 /A204) to OHIP for the office visit and medical examination in support of this procedure?

No. Any services rendered to any patient in support of IVF are uninsured and claims for these services cannot be submitted to OHIP.

As this is a funded IVF cycle under the Fertility Program, surgical sperm aspiration services are included in the bundled IVF payment to the participating clinic. Participating clinics are responsible for remunerating physicians for services rendered, and the patient cannot be charged for these services.

Resources

Physician or clinic inquiries related to OHIP claims submissions and payments should direct their questions to the Service Support Contact Centre (SSCC) at 1-800-262-6524.

Schedule of Benefits for Physician Services

OHIP INFOBulletins: #4662 and #4663

The latest version of the Schedule is available.

Hard copies of the Schedule will not be distributed. If you would like to order a paper copy or compact disk (CD) of the Schedule for a fee, please visit ServiceOntario Publications.

Physicians without access to the Internet can contact ServiceOntario at 1-800-668-9938.

This Bulletin is a general summary provided for information purposes only. Physicians, hospitals, and other health care providers are directed to review the Health Insurance Act, Regulation 552, and the Schedules under that regulation, for the complete text of the provisions. You can access this information at ontario.ca/e-laws. In the event of a conflict or inconsistency between this bulletin and the applicable legislation and/or regulations, the legislation and/or regulations prevail.


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For More Information

Call ServiceOntario, Infoline at:
1-866-532-3161 (Toll-free)
In Toronto, (416) 314-5518
TTY 1-800-387-5559.
In Toronto, TTY 416-327-4282
Hours of operation : Monday to Friday, 8:30am - 5:00pm