Ontario Health Insurance Plan

INFOBulletin

New Temporary Virtual Care K-Code K084A

K084A enables billing for payments equivalent to selected specialist premiums for claims previously submitted under K083A


To: All Providers
Category: Physician Services
Written by: Claims Services Branch, Ontario Health Insurance Plan Division
Date issued: October 9, 2020
|Bulletin Number: 201003


To continue supporting the government’s efforts in response to the COVID-19 outbreak in Ontario, the Ministry of Health (ministry) and the Ontario Medical Association (OMA) have reached an agreement to temporarily fund payments that are equivalent to the rates in the Schedule of Benefits for Physician Services (the Schedule) for eligible premiums when related to the provision of the temporary virtual care K-code services.

Further to INFOBulletin 4764 titled ‘Equivalent Payments for Selected Premiums and Management Fees related to the Temporary COVID-19 Virtual Care K-Codes’ a new temporary fee schedule code (FSC) has been implemented.

New Fee Schedule Code

Effective October 1, 2020, the ministry implemented a new temporary FSC to enable physicians to bill for payments equivalent to selected specialist premium amounts when they have previously submitted claims for payments under K083A which did not include the value of any applicable specialist premiums.

The new FSC used to process these payments is: K084A: Premium Equivalent for Virtual Care

Claims Submission

  • K084A can only be billed for services where a K083A was billed between March 14, 2020 and August 6, 2020 and the eligible premium amount was not included.
  • If a Remittance Advice Inquiry (RAI) has already been submitted to adjust a previous claim that included K083A, do not submit a claim for the K084A. The claim will be adjusted through the RAI or bulk adjustment process already received.
  • A stale date exemption will automatically be applied to K083A and K084A until December 11, 2020 due to the delay in implementation to allow physicians enough time to submit claims.
  • To determine the number of K084A services to submit, first calculate the value of the equivalent service to K083A plus any applicable specialist premiums. Round to the nearest $5 and divide it by 5 to get the total number of services eligible for payment. Subtract the number of services previously submitted for K083A and bill the remaining number of services as K084A.
  • Effective for service dates of August 7, 2020 or greater, if a physician has submitted claims for payment using K083A and did not include the value of an applicable specialist premium equivalent to those listed above, a RAI must be submitted in order to adjust those claims.
  • If submitting an original claim for K083A that is eligible for more than 99 services, submit the first K083A code for 99 services and submit an additional K083A for the remaining number of services with a manual review indicator. This will allow the claims offices to manually adjudicate these claim items and pay appropriately. Supporting documentation will not be required for these items.

Examples

Examples

Equivalent to

Scenario

Action

A neurologist (18) provides a virtual Medical Specific Assessment (equivalent to A183) to a patient with multiple sclerosis, which qualifies for a chronic disease assessment premium equivalent (calculated at rate of E078A – add 50%)

A183A = $79.80
E078 = $39.90
Total: $119.70 (24 units)

Specialist billed the K083A as 16 units for service date of April 15, 2020.

 

Bill K084A as 8 units for the same service date.

A pediatrician provides a consultation (A265A) to a patient aged less than 30 days (age premium < 30 days – add 30%)

A265A = $175.40
Age premium = $52.62
Total: $228.02 (46 units)

Specialist billed the K083A at 46 units with a service date of May 10, 2020.

 

Nothing to be done.

A pediatrician provides a consultation (A265A) to a patient aged less than 30 days (age premium < 30 days – add 30%)

A265A = $175.40
Age premium = $52.62
Total: $228.02 (46 units)

Specialist billed the K083A at 35 units with a service date of August 10, 2020.

Submit an RAI and have the claim adjusted to include the additional 11 units for the eligible premium portion.

A psychiatrist provides a special psychiatric consultation (A190A) to a patient, which then qualifies for a K189A (Urgent community psychiatric follow-up -$216.30)

A190A = $300.70

Follow-up = $216.30
Total: $517.00 (103 units)

Not yet billed.

Submit a K083A claim retroactive to July 1, 2020 at 99 units. Submit an additional K083A with 4 units using a manual review indicator.

Important Additional Terms and Conditions

By claiming and accepting the payments that are equivalent to eligible premiums, physicians will be deemed to agree to the following terms and conditions:

  • All payment requirements in the Schedule that are applicable to specialist premiums must be met for these premiums to be payable. Where the Schedule requires a specific fee code or service, K083A will be accepted as meeting that requirement.
  • The same claims submission requirements for insured services in Regulation 552 under the Health Insurance Act must also be met when submitting claims for the Specialist Premiums described above (e.g. including physician billing number, patient health number, etc.).

Keywords/Tags

COVID-19; K084A; K083A

For more information

For any further inquiries, please contact the Service Support Contact Centre via email or by phone at 1-800-262-6524.

The latest version of the Schedule of Benefits for Physician Services is available on the Ministry of Health website. Hard copies of the Schedule of Benefits for Physician Services 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 Publications Ontario. 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 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/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.

Find INFOBulletins online on the Ministry of Health website.

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