Ontario Health Insurance Plan

INFOBulletin

Release 5 Changes and K229A Eligibility Incident Resolution

New Hospitalist and Internal Medicine Premiums implemented; Physician eligibility fix for K229A


To: All Providers
Category: Physician Services
Written by: Claims Services Branch, Ontario Health Insurance Plan Division
Date issued: November 17, 2020
Bulletin Number: 201106


The Ministry of Health (ministry) and the Ontario Medical Association (OMA) have been working together to implement physician compensation increases in accordance with the 2019 Kaplan Board of Arbitration Award.

This will be achieved through amendments to physician compensation under contracts and to regulations under the Health Insurance Act, including the Schedule of Benefits for Physician Services (Schedule).

Please see INFOBulletin 4762 and INFOBulletin 4753 for a summary of all Schedule changes effective April 1, 2020. These changes are being implemented in the OHIP claims system through phased releases.

The following Release 5 changes are being implemented November 1, 2020 with an effective date of April 1, 2020.

Hospitalist Premium

Physicians with specialty designations 00 (General and Family Practice) or 13 (Internal Medicine) who are practicing as a Hospitalist and submitting claims for the following qualifying services at the specified levels are eligible for the Hospitalist Premium:

  • A933A-On-call admission assessment
  • C933A-On-call admission assessment
  • C002A-Subsequent visit-first five weeks
  • C007A-Subsequent visit-6th to13th weeks
  • C009A-Subsequent visit-after 13th week
  • C122A-Subsequent visit by Most Responsible Physician-day following hospital admission assessment
  • C123A-Subsequent visit by Most Responsible Physician-second day following the hospital assessment
  • C124A-Subsequent visit by Most Responsible Physician-day of discharge
  • C132A-Subsequent visit-first five weeks
  • C137A-Subsequent visit-6th to13th week
  • C139A-Subsequent visit-after 13th week
  • C142A-First subsequent visit by Most Responsible Physician following transfer from an Intensive Care area
  • C143A-Second subsequent visit by Most Responsible Physician following transfer from an Intensive Care area
  • C882A-Palliative care-General Practitioner
  • C982A-Palliative care-all other specialties
  • E082A-Admission assessment by the Most Responsible Physician premium

Eligible physicians will receive a premium of 17% of the approved amount on the qualifying services, except for E082. The E082A helps determine eligibility when not billed with A993A or C993A, but E082 itself is not eligible for the premium. The premium is based on service encounters and requires a minimum of 1,500 qualifying services claimed on at least 110 distinct days in the previous fiscal year (April 1-March 31).

For eligible claims submitted on or after November 1, 2020, the Hospitalist Premium payments will be made monthly and will be reported on the Remittance Advice (RA) under the Premium Payments section. The first payment will appear on the December RA.

Premium payments based on previously-submitted claims for qualifying services with service dates for the period of April 1, 2020 to October 31, 2020 will be made via separate payment(s). More details will follow in a future INFOBulletin.

Note: No action is required for physicians for previously-submitted claims.

Internal Medicine Office Assessment Premium

Physicians who are practicing solely as a general internist and who have submitted all claims using the specialty designation of Internal Medicine (13) in the qualifying year are eligible for a premium of 12% of the approved fee amount on the following qualifying services:

  • A133A-Medical specific assessment
  • A134A-Medical specific re-assessment
  • A131A-Complex medical specific re-assessment
  • A138A-Partial assessment

For eligible claims submitted on or after November 1, 2020, the Internal Medicine Office Assessment Premium payments will be made monthly and will be reported on the RA under Premium Payments section. The first payment will appear on the December RA.

Premium payments based on previously-submitted claims for qualifying services with service dates for the period of April 1, 2020 to October 31, 2020 will be covered by a separate payment(s). More details will follow in a future INFOBulletin.

Note: No action is required for physicians for previously-submitted claims.

K229A-Complex genetic test interpretation

K229A is restricted to physician specialists in genetics and/or specialists with a Fellow of the Canadian College of Medical Geneticists (FCCMG) designation. As such, claims for K229A can be submitted by physicians that have a specialty other than Genetics (22) when they also have FCCMG designation.

Previously submitted claims that rejected ‘A4D-Ineligible Specialty’, can be resubmitted for payment as of November 1, 2020, with the exception of claims that may now be stale-dated. For these claims or for claims not yet submitted for services which may now be stale-dated, the ministry is planning on implementing a system change to provide an exemption until December 31, 2020. This change is tentatively planned to be implemented on December 1, 2020 and will be communicated once confirmed.

For more information

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.

Keywords/Tags

Kaplan; K229A; Hospitalist Premium; Internal Medicine Office Assessment Premium; Year 4; Release 5

Contact Information

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

Find INFOBulletins online on the Ministry of Health website.
  • Connect With Us
Facebook Twitter YouTube RSS