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Ontario Health Insurance Plan

OHIP Bulletins


Interprovincial Health Care InfoBulletins

To:  Hospital

Published by:   Health Services Branch

Date Issued:  July 13, 2016

Bulletin Number:  NA74

Re:  Medically necessary services provided in Ontario hospitals to residents from other provinces – Update


This document is an update of INFOBulletin NA60, going forward, please refer to this document on this topic.

This is a reminder to Ontario hospitals to submit claims for services rendered to out-of-province (OOP) residents through the reciprocal hospital billing system.  When a valid health card is presented, hospitals should not charge the patient for the provision of medically necessary hospital services.  For images of valid provincial/territorial health cards, please refer to the interprovincial health card poster available from your Local Health Integration Network.

All provinces and territories participate in reciprocal hospital billing agreements. In keeping with the intent of the Canada Health Act's (CHA) portability provisions, the intention of these agreements is to avoid and/or limit the exposure of undue financial burden on Canadians if they require medically necessary care when in another province or territory in Canada.  As such, reciprocal hospital billing systems have been put in place in provinces and territories, including Ontario, to facilitate ease of billing and payment of hospital services when treating OOP patients.

Each year all provinces and territories agree upon hospital rates to be charged by each hospital captured under the interprovincial agreements for providing care to patients from other jurisdictions.  As such, when an insured resident of another province or territory presents for insured medically necessary health care services he or she should not have to pay for the services (provided a valid health card is presented – e.g., if the card has an expiry date and it has not expired).  Therefore, it is the ministry's expectation that Ontario hospitals bill for both in-patient and out-patient services reciprocally and not charge the patient for insured health care services if a valid health card is shown. For patients referred to the hospital for medically necessary laboratory work or other diagnostics including X-rays, there are approved out-patient service codes that apply and these services should be billed reciprocally.  Similarly, a referred-in laboratory specimen (where the patient is not present), is also considered an out-patient service and should be billed reciprocally.

For patients that do not present with a valid health card, it is expected that the hospital charge the patient the approved in-patient or out-patient rate so that the patient can be reimbursed fully by their insuring province or territory, if they are eligible.

Note that for out-patient services, the approved fee is a composite rate which includes interpretation; therefore, there should be no physician charge for interpretation of laboratory and/or other diagnostic services in addition to the reciprocal claim regardless of who interprets the specimen or test.

In the event that a Canadian province or territory is not reimbursing for reciprocally billed claims when a valid health card has been viewed by hospital staff, and the claim is properly submitted, please notify the ministry by sending an email to:

InterprovinceBilling.moh@ontario.ca
or writing to:
Program Manager, Out-Of-Province Program
Policy and Projects
Health Services Branch
1055 Princess Street, Box 168
Kingston ON  K7L 5V1

Thank you for your cooperation.


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