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Ontario Health Insurance Plan

OHIP Bulletins

Physician Services InfoBulletins

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

Published by:   Ontario Public Drug Programs

Date Issued:  July 25, 2016

Bulletin Number:  4676

Re:   Nurse Practitioners: Referrals and Delegated Procedures

PDF Version Portable Document Format

Referrals from Nurse Practitioners

As detailed in INFOBulletin #4653, effective May 1, 2015, amendments to the Schedule of Benefits for Physician Services (the Schedule) were approved to permit payment under OHIP to physicians for consultations when patients are directly referred by Nurse Practitioners (NPs).

Payment Issue Related to Referrals from Nurse Practitioners

Prior to April 1, 2016, claims submitted with an NP's six digit OHIP identification number as the referring provider were being rejected when another service was submitted on the same claim. This issue has been resolved.

Physicians may resubmit rejected claims related to NP referrals for payment.

If physicians are still experiencing claim rejections associated with NP referrals, please contact the Service Support Contact Centre at 1-800-262-6524.

Reminder – Use of NP Referral Number in Submitting Claims

The NP's six digit OHIP identification number is required to be submitted with the claim for the referred consultation.

However, the NP's six-digit OHIP identification number is not required to continue to be submitted to note the referring provider for services to the patient beyond the initial consultation, except for requests for a consultation service (i.e., consultation, limited consultation, repeat consultation).

If a claim for a service that does not require a referral is mistakenly submitted with an NP's OHIP number as the referring provider, the claim will not reject.

Delegation – Services Rendered by Nurse Practitioners

A physician must personally perform most services listed in the Schedule for these services to be insured and payable by OHIP.

The Schedule is specific regarding services that must be performed personally by the physician and cannot be delegated to a Nurse Practitioner for OHIP payment purposes, including consultations, assessments, counselling, and interpretation of diagnostic imaging. These services are only payable when performed personally by the physician and cannot be claimed and are not payable if delegated or performed by an NP.

Services that can be delegated to an employee of the physician and paid by OHIP are very limited. Generally, services provided by NPs, even when they are within the NP's scope of practice, cannot be billed by a physician employer except for a few narrowly defined services (e.g., injections, venipuncture).

These services are payable to the physician as long as the payment requirements outlined in the Schedule for delegated procedures are met. The payment requirements include:

  • The procedure is performed by a physician's employee in the physician's office;
  • The procedure is one which is generally and historically accepted to be delegated; and
  • The physician is physically present in the office or clinic; unless the exceptions listed in the Schedule are met.

Please see the General Preamble of the Schedule titled Delegated Procedure for the complete detailed requirements.

Claims are not payable if provided by an individual who is employed by a facility or organization. Subject to the exceptions in the table on page GP42 of the Schedule, the physician must also be physically present and immediately available.

NP Contributions to Primary Health Care Physician Special Premiums

Eligible services provided by an NP affiliated to a primary care enrolment model (PEM) and submitted with the NP's six digit OHIP identification number will contribute to accumulations for a PEM physician's Special Premium payment for Home Visits, Prenatal Care, and Office Procedures.

There is no limit on the number of NP's that may be affiliated with a PEM and an NP may be affiliated with more than one PEM at the same time.

An affiliated NP may submit claims using the NP's six digit OHIP identification number for eligible services that are within his/her scope of practice as described in the Regulated Health Professions Act, 1991 (RHPA) and the Nursing Act, 1991, are delegated by physician(s), or are covered by a medical directive in the appropriate situation.

Note: This does not in any way change or affect the delegation of service rules as set out in the Physician Schedule of Benefits or the RN (EC) Scope of Practice as described in the Regulated Health Professions Act, 1991 and the Nursing Act, 1991. In addition, submission of claims for these premiums does not change any program requirements the NP may currently have with regards to performance reporting.

Eligible services submitted with the NP's six digit OHIP identification number will be processed and paid at zero dollars. Any services that are not eligible for contribution to a physician's Special Premiums will reject to the NP's claims error report with the error code ‘EPA – PCN billing not approved’. Please refer to your primary care agreement for the list of eligible services that contribute to each of the applicable Special Premiums.

Services submitted by an NP affiliated with your group will be reported on the Payment Summary Report on the physician's solo and group RA.

To view Portable Document Format PDF files, you will need to have Adobe Acrobat® Reader installed on your computer. You can download this free software from the Adobe website.

For More Information

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