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Ontario Health Insurance Plan

OHIP Bulletins


INFOBulletin

Keeping Health Care Providers informed of payment, policy or program changes

To: All Provider(s)

Published by: Claims Services Branch, Ministry of Health

Date Issued: December 17, 2019

Bulletin Number: 4736

Re: Kaplan Board of Arbitration Award – Appropriateness Working Group (AWG): Additional Specialist Consultations Changes to the Schedule of Benefits Effective October 1, 2019

Posted Electronically Only

PDF Version


As directed by the February 2019 Kaplan Board of Arbitration Award, the Ministry of Health and the Ontario Medical Association (OMA) formed the Appropriateness Working Group (AWG) with a mandate to use evidence, best practices and expert opinion to identify and update the delivery of certain services to help ensure the most effective care for Ontario patients.

  • As a result of recommendations from the AWG (refer to INFOBulletin # 4726), effective for service dates on or after October 1, 2019, consultations rendered by the same physician, to the same patient, for the same diagnosis are now only eligible for payment once every 24 months when provided in the office.
  • With this change, the following provisions apply:
    • If an additional consultation is submitted by the same physician, for the same patient, with the same diagnosis, within a 24 month period, and is not provided to a patient who has been admitted to hospital or seen in the Emergency Department, the claim will be rejected to the providers error report with error code ‘AC1 – Maximum Reached Resubmit Alternate FSC’
    • Any additional assessments rendered by the same physician, to the same patient, for the same diagnosis, are payable using the appropriate assessment code listed in the Schedule.
    • One additional consultation rendered by the same physician, to the same patient is also eligible for payment once every 12 month period if rendered for a clearly defined unrelated diagnosis.
    • OHIP continues to insure any medically necessary visits beyond the above limits for the same provider to the same patient with the same diagnosis under existing appropriate general, medical specific or specific assessments (depending on the specialty of the physician).
    • Repeat consultations as per the Schedule, remain eligible for payment in the circumstances defined by the fee code, namely following a consultation where the referring physician renders interval care but refers the patient back to the physician for additional advice.
    • Consultations are not eligible for payment if requested by a Medical Trainee. However, these services are eligible for payment at the appropriate assessment fee code amount dependent on specialty.

Claim Submission Rejections – Specialist Consults

  • Please note that claims submitted appropriately for an additional consult by the same provider to the same patient but with a different diagnosis within the same year have incorrectly been rejected by the claims payment system. The medical rule that caused these rejections has been identified, and a solution is being generated.
  • Once the rule has been amended, a notification will be provided so that physicians may resubmit the rejected claims for processing.

Claims Adjustment

  • Claims submitted with service dates on or after October 1, 2019, that were previously paid, will be adjusted accordingly to reflect the new payment rules in the Schedule.
  • You will be notified once the adjustment processing begins.

For details related to the AWG changes to the Schedule effective October 1, 2019, please refer to INFOBulletin # 4726 Kaplan Board of Arbitration Award - Appropriateness Working Group (AWG): Changes to the Schedule are effective October 1, 2019.

For any further inquiries, please contact the Service Support Contact Centre at 1-800-262-6524.

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

 
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