The following are circumstances in which the General Manager of OHIP may take action on physician claims :

1. prior to making payment, to refuse or reduce the amount claimed, under section 18(4) of the Health Insurance Act,
   or
2. after making payment, to notify a physician of a potential requirement that the physician reimburse an amount, under section 18(11) of the Health Insurance Act.

Restricted practice

• Claim for a service performed while the physician is prohibited from performing such due to a term, condition and/or limitation that has been imposed upon his or her certificate of registration

Deceased patient or deceased physician

• Claim for service performed after date of death of the physician
• Claim for service performed after date of death of the patient, other than :
• claim for pronouncement of death; or
• appropriate claim(s) for pathology specimens

Keying and administrative errors

• Exchanging two letters that are side by side on the keyboard where the result is a claim for a fee code normally billed by a different specialty than that of the physician submitting the remittance (e.g., a family medicine practitioner typing an "S007" (resection of mandible surgery) rather than an "A007")
• Transposed order of digits (as determined by patient’s claim history and physician specialty) specifically listed below :

Fee Code Submitted	Intended Fee Code
E340A	E430A

• Incorrect date of service where such is evident from other claims submitted by the physician
• Claim amount keyed incorrectly by the ministry into the ministry's Online Claims Correction System (e.g., paid $1,028.00 instead of $128.00)

Billing for hospital inpatients

• For all fee codes that the schedule of benefits prohibits being billed for an admitted patient, between the time a patient is admitted to a hospital and the time a patient is discharged

Prohibited code combinations

• Code combinations expressly prohibited in the schedule of benefits

Errors explicitly acknowledged by a physician

• Where a physician has explicitly acknowledged, in writing, that a claim was incorrect.
  Comment: this circumstance would provide a convenience for physicians, bypassing the need for the physician to submit the necessary changes in the form of revised claims. Some examples where this has occurred in the past as the result of verification letter inquiry : no service provided; incorrect health number (service provided to another insured patient); incorrect fee code

Duplicate or other prohibited claims submissions

• Second and subsequent claims by the same physician or other physicians for the same service to a patient
• Fee-for-service claims by a physician who is party to an alternative payment plan agreement, for services that are within the scope of the agreement and for which fee-for-service payments are prohibited by the agreement

Circumstances covered by current computerized checks, and the following :

• Birth-related claim for: female with previous hysterectomy claim; female with previous birth-related claim within 8 months or less; female aged 10 years or younger; female aged 55 or older; male

Note : Circumstances covered by computerized checks will be published on the Internet when they are available in an easy-to-read format.