OHIP billing

The Ministry of Health has announced extensions to the following temporary COVID-19 funding initiatives:

• The Temporary Summer Locum Program will conclude on March 31, 2024
• The after-hours premiums fee codes (E409 and E410) for physicians performing specified elective surgical and other procedures after hours will conclude on March 31, 2024
• The Emergency Department Alternative Funding Agreement surge funding has been extended to March 31, 2024, with a scheduled reduction of base funding each quarter. For additional details, please contact the EDAFA lead within the respective department

The Assessment Centre sessional fee codes (H409, H410) expired on June 30, 2023.

Funding for the following COVID-19 initiatives expired on March 31, 2023:

• Physician hospital funding, including:
• Hourly rates to replace regular fee-for-service payments in intensive care units and inpatient wards
• Hourly rates to replace FFS payments for Protective or Pre-Emptive Code Blue Teams. Option for hospitals to have physicians receive a 30 per cent modifier payment on three critical care fee codes (G521, G522, G523) in lieu of hourly funding
• Hourly rates for non-clinical assignments. Extended to physicians deployed by hospitals to conduct non-clinical work related to COVID-19 in long-term care homes and congregate care settings
• Additional FTE funding for infectious disease specialists where the hospital has an existing infectious disease specialist who is not at 1.0 FTE equivalent
• Thirty per cent modifier payment for Aerosol-Generating Medical Procedures (AGMP) performed on patients who are COVID-19 positive or who are at risk of being COVID-19 positive
• Hourly rates for residents on CPSO-restricted registration certificates.
• Thirty per cent modifier payment for eligible AGMPs performed outside hospitals

The OMA Negotiations Task Force has successfully negotiated an agreement with the Ministry of Health to extend funding for administering COVID-19 vaccines retroactive to Nov. 1, 2021, through to March 31, 2024.

In March 2021, the board approved an agreement for fee-for-service compensation for administering the initial series of COVID-19 vaccines.  This agreement was set to expire on March 6, 2022. 

This new agreement applies to the administration of COVID-19 vaccines, including booster doses and extends the significantly enhanced compensation to physicians for administering COVID-19 vaccines on a fee-for-service basis. 

• The agreement would extend the temporary fee code (G593) payable at $13.00 for each dose of COVID-19 vaccine administered
• If the vaccination is provided as a sole reason for the visit, FFS/CCM/FHG physicians would bill the G593 and the G700 (existing sole visit premium for vaccination, $5.60) for a total remuneration of $18.60 per vaccination
• All other Primary Care Enrolment Model (PEM) physicians, including FHOs would bill the G593 and Q593 (sole visit premium COVID-19 PEM, $5.60) when the vaccination is the sole reason for the visit, for total remuneration of $18.60
• If other insured services are rendered on the same day, by the same doctor, to the same patient as a COVID-19 vaccine, G593 will be payable in full ($13.00) for the vaccination and the other appropriate visit fees can also be billed for the other services provided
• G593 continues to be a service that can be delegated
• G593 and Q593 will continue to be out of basket for all primary care models and G593 is not eligible for the FHG Comprehensive Care Premium
• The original agreement provided for a temporary fee code (Q007) payable at $6.00 if physicians receive a formal request from a Public Health Unit or the province to contact identified groups of patients to assist in the registering/booking their patients’ COVID-19 vaccination or to provide direct assistance in completing patient consent or other documentation. This fee code was not payable where physicians only provide general information about how to access or register for a vaccination. The Q007 will expire as scheduled on March 6, 2022

Additional resources

FAQs: Temporary COVID-19 Physician Funding Extension

MOH: ADM Memo — Extension of Temporary Physician Funding for Hospitals During COVID-19 and Physician Virtual Care (“K-codes”), July 30, 2021

OHIP INFOBulletin — Extension of Temporary COVID-19 Physician Services

OHIP INFOBulletin — Extension of Temporary COVID-19 Primary Care Physician Services

From the InfoBulletin 230602, the H409 and H410 expired on June 30, 2023.

Billing in COVID-19 Assessment Centres after June 30, 2023: Physicians who continue to provide care in COVID-19 Assessment Centres beyond June 30, 2023 may submit fee-for-service claims for insured services rendered using the appropriate fee codes listed in the Schedule of Benefits for Physician Services.

If you have further questions, please contact the ministry’s Service Support Contact Centre (SSCC) by email at SSContactCentre.MOH@ontario.ca or by calling 1-800-262-6524.

The OHIP Schedule of Benefits for Physician Services lists numerous forms that are insured under the provincial health plan. This table lists insured forms from the June 29, 2023, Schedule.

The OHIP Schedule of Benefits lists forms that are uninsured but billable to OHIP in Appendix F. The services set out in Appendix F are not “insured services” within the meaning of the Health Insurance Act, but are paid by the MOH, acting as a paying agent.

Physicians can submit claims through OHIP using the following fee schedule codes found in Appendix F.

There are various forms that are required by legislation to complete, which may not be charged to the patient, and may not be submitted to OHIP for payment. Section 24 of the Health Insurance Act R.R.O. 1990, Regulation 552 Amended to O. Reg. 352/04 stipulates what is considered an “uninsured” service and what cannot be submitted to OHIP for payment.

Some examples of unremunerated forms include:

• Application for accessible parking permit (002-SR-LV-129E)
• Accessible transit eligibility application forms
• Children’s Aid Society forms (on behalf of a child)
• Ministry of Health forms (ADP Assistive Device forms, etc.)

What is an after-hours premium?

An after-hours premium may be eligible for payment when rendering an applicable service during unsociable time periods and/or days (e.g., evenings, nights, weekends and holidays), as defined in the Schedule of Benefits. Services that may be applicable for an after hours premium include:

• Selected procedures
• Surgical assistant services
• Anesthesia services
• Urgent CT/MRI interpretation services
• Selected primary care assessment fees

After-hours procedure premiums

These premiums are payable only when the following criteria are met:

• The service provided is one of the following: non-elective surgical procedures (including fractures or dislocations), obstetrical deliveries, clinical procedures associated with diagnostic radiological examinations, ground ambulance transfer (K101), air ambulance transfer (K111), transport of donor organs (K102), return trip (K112), or a major invasive procedure
• The procedure is either non-elective or an elective procedure that, because of an intervening surgical emergency procedure(s), was delayed and commenced between 5 p.m.-7 a.m., Monday to Friday, or daytime and evenings on Saturdays, Sundays and holidays

After-hours premiums for urgent CT/MRI interpretation services

The after-hours premiums for urgent CT/MRI interpretation services are only eligible for payment for an acute care hospital in-patient, emergency department or hospital urgent care clinic patient. In addition, the following requirements must be satisfied:

• The referral for the interpretation relates to a patient’s condition that requires urgent interpretation of a CT or MRI study for the urgent management of the patient
• The referral is from a physician or oral and maxillofacial surgeon who has privileges at the hospital where the service is rendered
• The interpreting physician has radiology privileges at the hospital where the request for the service originates
• The interpretation is transmitted to the referring physician within three hours of the completion of the CT/MRI study

If the request for interpretation occurs prior to an eligible after-hours period, but the interpretation cannot be provided prior to that eligible after-hours period due to factors beyond the control of the interpreting physician, these premiums remain eligible for payment if the payment rules are otherwise satisfied.

Primary care after-hours premiums

Primary care physicians enrolled in an applicable model can receive a 30 per cent premium on the value of the following fee codes: A001A, A003A, A004A, A007A, A008A, A888A, K005A, K013A, K017A, K030A, K033A, K130A, K131A, K132A, K133A, Q050 and Q888. In order to receive the premium, Q012A or Q016A must be submitted.

Payment rules and requirements:

• After-hours premiums are not applicable for services rendered between 8 a.m.-5 p.m.
• The after-hours premiums may be billed for enrolled patients seen during regular after-hour services held after 5 p.m. on weekdays or any time on weekends or statutory holidays
• The services must be available to scheduled and non-scheduled patients. The services must be held during regularly scheduled times and the physician must make their patients aware of the dates and times such services are available
• Premiums should not be billed for patients who are seen after 5 p.m. because the physician’s clinic is behind schedule
• Physicians must be available during regular office hours to provide comprehensive care to their patients. This obligation is specified in the FHG and FHN agreements and other agreements
• It is not acceptable to alter regular daytime office hours solely for the purposes of billing the after-hours premium

Physicians could inform their patients about their after hour schedules by posting hours in the waiting room, including this information on the practice voicemail greeting, producing a practice newsletter with the hours included or sending patients letters/emails.

Learn more about after-hours premiums in the reference guide.

P009 (attendance at Labour and Delivery) is payable for attending labour and delivery when the physician either assists at vaginal delivery or surgery, gives anaesthetic at a caesarean section or operative delivery, or resuscitates the newborn.

It is important to note that in order to bill P009, the component services of attendance at labour must be met. Obstetric Preamble, paragraph “e” describes attendance at labour as “a service of being in constant or periodic attendance on a patient, during stages one and two of labour but without completion of the delivery, to provide all aspects of care. This includes the initial assessment, and such subsequent assessments as may be indicated, including ongoing monitoring of the patient’s conditions, intervening except where intervention is a separately billable service.”

This code is for use by a physician who has been providing obstetrical care to a patient during labour but who has required the services of an obstetrician for delivery. It cannot be billed by an obstetrician or other specialist. It may only be billed once per patient.

Read the frequently asked questions.

Case conferences are time-based services calculated in 10-minute increments with a maximum of eight units per individual case conference and a maximum of four case conferences per 12-month period, per patient, per physician.

Payment eligibility

Each case conference is subject to specific payments requirements listed under the respective fee code; however, the following service requirements must be satisfied by all case conferences:

• A case conference must be conducted by personal attendance, videoconference or by telephone (or any combination thereof)
• It must involve at least two other eligible participants as specified in the specific case conference service 
• At least one of the physician participants is the physician most responsible for the care of the patient
• The physician must actively participate in the case conference and such participation is evident in the medical record
• There must be a minimum of 10 minutes of patient-related discussion
• The case conference must be pre-scheduled

Payment exclusions

A case conference is not eligible for payment: 

• In circumstances where a physician claiming the service remunerates other participants who are necessary to meet the minimum requirement
• To a physician who receives payment for the preparation and/or participation in the case conference other than by fee-for-service (includes compensation where the physician receives remuneration under a salary primary care, stipend, APP or AFP model)
• Where it is an included element of another service (e.g., Chronic dialysis team fees) 
• When the service is rendered for educational purposes such as rounds, or continuing professional development, or any meeting where the conference is not for the purposes of discussing and directing the management of an individual patient
• If another case conference or telephone consultation has already been paid for the patient on that day

Medical record requirements

In order to fully satisfy payment requirements, the medical record must include all of the following elements:

• Identification of the patient
• Start and stop time of the discussion regarding the patient
• Identification of the eligible participants, and
• The outcome or decision of the case conference

For billing purposes, one common medical record in the patient’s chart for the case conference signed or initialled by all physician participants (including listing the time the service commenced and terminated and individual attendance times for each participant if different) would satisfy the medical record requirements.

In circumstances where more than one patient is discussed at a case conference, separate claims for each patient are eligible for payment, provided all payment requirements are fulfilled for each individual patient.

Any other insured service rendered during a case conference is not eligible for payment.

Read more about payments for case conference services.

Even if you assign a staff person or have a billing agent submit claims on your behalf, you are ultimately responsible for the claims submitted to ensure appropriate and timely payment of OHIP claims.

OHIP claims submission reports

To ensure prompt and correct payment, it is imperative to review the following OHIP claim submission reports once available:

• Claims batch edit report
• Error report
• Remittance advice 

These reports provide insight on the status of your claims and, where a claim was not paid as submitted, the reason it was not paid and the appropriate course of action to reconcile the claim.

Claims data may be subject to rejection by the Ministry of Health at three levels:

• Rejection of entire file submission
• Rejection of batch within a file
• Rejection of a claim within a batch

Claims batch edit reports

If a file is accepted, a claims batch edit report is sent to acknowledge receipt and note whether the batch is accepted or rejected. An entire batch or file may be rejected; consequently, it is recommended that batches be maintained at a manageable size (e.g., batches should not exceed 500 claims and file size should not exceed 10MB). 

Error report

Rejected individual claims/items will appear on an error report with the appropriate error code(s). The claims error report is sent to the medical claims electronic data transfer user ID that was specified at the time of application. These claims must be corrected and resubmitted within six months from the date of service in order to be considered for payment.

Claims within a batch will be rejected for any of the following reasons:

• Missing/invalid data as per the field description specified by error code(s) prefixed with “V”
• Ineligible patient/health-care provider data (specified by error code(s) prefixed with “E”)
• Missing/invalid data as specified in the Schedules of Benefits (specified by error code(s) prefixed with “A”)

Remittance advice

Remittance advice is a monthly statement of approved claims and is issued on or about the fifth working day of the month, prior to receipt of payment. The remittance advice file contains accounting details of claims approved during the ministry’s previous claims processing cycle. It will also contain explanatory codes to clarify payment exceptions.

The remittance advice may also contain general communication or messages from the ministry.

Upon review of the remittance advice, should there be any inquiries regarding an overpayment, underpayment or a claim submission that was modified by the ministry, the inquiry should be submitted within four months to your claims processing office on a Remittance Advice Inquiry form (form #0918-84). 

Claims requiring documentation

In cases where you are required to submit supporting documentation and/or know you are submitting a complex claim that will likely require supporting documentation (e.g., claim submission involving several fee codes), use your billing software to flag the claim with a manual review indicator. This will notify your OHIP claims processing office that the submission requires special attention.

For additional information, read the claims reconciliation and remittance advice inquiry processes reference guide.

The Schedule defines a consultation as “an assessment rendered following a written request from a referring physician or nurse practitioner who, in light of his/her professional knowledge of the patient, requests the opinion of a physician (the “consultant physician”) competent to give advice in this field because of the complexity, seriousness, or obscurity of the case, or because another opinion is requested by the patient or patient’s representative.”

Except where otherwise specified, the consultant is required to perform a general, specific or medical specific assessment, including a review of all relevant data.

Payment rules and medical record requirements

If the following requirements are not met, the amount payable for a consultation will be reduced to a lesser assessment fee.

All consultations

The criteria are:

• The request for consultation must be in writing and signed by the referring physician or nurse practitioner
• The request must identify the consultant by name, the referring physician/NP by both name and billing number, and the patient by both name and health number
• The request must clearly state information relevant to the referral and specify the service(s) required

A copy of the written request must be retained in the consulting physician’s medical record except in the case of a consultation that occurs in a location where common medical records are maintained (e.g., hospital). In such cases, the request may be contained on the common medical record.

Emergency department consultations

ER reports constitute adequate documentation of the written report of the consultation as long as the rendering of all constituent elements is clearly documented on all copies of the report. Upon failure to provide the ER report to the referring physician/NP, the amount payable for the service will be adjusted to the amount payable for an assessment

Time-based consultations

The requirements are:

• The service must satisfy all the elements of a consultation
• Start and stop times must be recorded in the patient’s permanent medical record

Service limits

Consultations, except for repeat consultations, to the same patient by the same physician for the same diagnosis are limited to one per two consecutive 12-month periods.

When a consultant has rendered a consultation service to a patient in any location, and the same consultant is referred to the same patient a second time with the same diagnosis, the number of consultations eligible for payment is two per two consecutive 12 month periods only when:

• The second consultation is rendered for a hospital inpatient or a patient in an emergency department
• The consultation is rendered more than 12 months but less than 24 months following the first consultation

Consultations rendered to the same patient by the same consultant with a clearly defined unrelated diagnosis are limited to one service every 12 months.

These limits are applicable to all consultations, including time-based and age-specific consultation services (e.g., special, extended and comprehensive consultations) but not repeat consultations.

For more information on OHIP payments for consultations, download the reference guide.

The Schedule allows a physician to bill OHIP for delegating a procedure that is generally and historically accepted as one that could be performed by a non-physician under the supervision of a physician.

The delegate may be any non-physician (e.g., physician assistant, nurse, nurse practitioner, etc.) who is properly trained to perform the procedure and where the procedure is one which is generally and historically accepted as a procedure, which may be carried out by the medical assistant. For the delegated procedure to be eligible for payment by OHIP, the delegate must be employed by the physician.

Physician services, such as assessments, counselling, therapy, consultations and diagnostic service interpretations cannot be delegated to a non-physician for OHIP payment purposes. These services must be personally rendered by the physician to be paid by OHIP.

For a delegated procedure to be eligible for payment, the procedure must be rendered in the physician’s office or clinic. Furthermore, the physician must be physically present to ensure that the procedure is performed correctly and must be immediately available to intervene where need be.

Download the guide on delegated procedures.

Family physicians working within one of the primary care models are eligible to bill for the e-consultation codes.

Physician to physician electronic consultation (“e-consultation”)

The Schedule of Benefits lists two services for physician to physician e-consultation: “K738” for the referring physician and “K739” for the consultant physician.

The Schedule describes an e-consultation as a service where a physician (the “referring physician”) requests another physician (the “consultant physician”) to provide their “opinion/advice/recommendations on patient care, treatment and management of a patient” where both the request and the response are sent by electronic means through a secure server.

Please note that K739 is not eligible for payment to dermatologists or ophthalmologists; these specialists would claim the appropriate specialty specific e-assessment code.

Payment rules and medical record requirements for K738

As described in the Schedule, the purpose of an e-consultation request by the referring physician is to seek the opinion of the consultant physician with the intent of the referring physician to continue the care, treatment and management of the patient. The K738 e-consultation service includes the transmission of relevant data (including family/patient history, history of the presenting complaint, laboratory and diagnostic tests) to the consultant physician and all other services rendered by the referring physician to obtain the advice of the consultant physician.

The referring physician is eligible to bill the K738 e-consultation service in addition to visits or other services provided to the same patient on the same day.

The Schedule explicitly states that a K738 e-consultation service is not eligible for payment where the intent of the e-consultation is for one of the following reasons:

• The purpose of the electronic communication is to arrange transfer of care of the patient to any physician
• Rendered in whole or in part to arrange for another service such as a face-to-face consultation (e.g. A005) or a procedure
• Rendered primarily to discuss results of a diagnostic investigation

K738 e-consultation service is also not eligible for payment in the following circumstances:

• The consultant renders a face-to-face consult, assessment or K-prefix time-based procedure the same day or the day after the e-consultation
• The physician receives compensation other than fee-for-service under the Schedule for participating in the e-consultation
• The consultant physician cannot or does not reply with advice or patient management options to the referring physician within 30 days

Under the OHIP Schedule, K738 and K739 are each limited to a maximum of:

• One service per patient per day
• Six services per patient, any physician, per 12-month period
• 400 services per physician, per 12-month period

The medical record requirements for billing K738 include:

• The record includes the patient’s name, health number, names of referring and consultant physician, reason for the consultation and opinion and recommendations of the consultant physician
• The billing number of the referring physician is included in the consultant’s claim for K739

Payment rule No. 7

E-consultation service payment rule No. 7 pertains only to e-consultation requests with a dermatologist or an ophthalmologist. 

In order for a primary care physician to be eligible to bill K738 when requesting an econsultation with a dermatologist or ophthalmologist, additional information not already contained in the patient’s medical record must be obtained. For example, a patient sees their primary care physician regarding a new skin rash. The primary care physician renders an
assessment, takes a photograph of the skin rash and then requests an e-consultation with a dermatologist. Since the primary care physician has “collected additional data to support” a dermatologist’s e-assessment, then K738 is eligible for payment.

Learn more in the payments for requesting e-consultation services guide.

A888 (Emergency department equivalent – partial assessment) is an assessment rendered in an emergency department equivalent on a Saturday, Sunday or holiday for the purpose of dealing with an emergency.

The term holiday means all of the following: Family Day, Good Friday, Victoria Day, Canada Day, Civic Holiday, Labour Day, Thanksgiving, New Year’s Day, Dec. 25 through Dec. 31 (inclusive) and, a) if Christmas Day falls on a Saturday or Sunday, the Friday before Christmas Day; and b) if New Year’s Day falls on a Saturday or Sunday, the Monday following New Year’s Day; and c) if Canada Day falls on a Saturday or Sunday either the Friday before or the Monday following Canada Day, as determined at the choice of the physician.

Physicians are restricted to using A888 for all assessments rendered in an emergency department equivalent, when the service occurs on a Saturday, Sunday or Holiday. The only assessment that can be claimed in an emergency department equivalent is A888, regardless of the level of assessment rendered.

A888 is only applicable for unscheduled appointments.

Download the guide for emergency department equivalent services payments.

Services provided to hospital patients, regardless of whether that service occurs in the emergency department, outpatient department or in-patient department, are to be claimed using the codes in the physician’s own specialty listing. This applies to services such as consultations, assessments and subsequent visits.

The exception is for the emergency department physician, which is a physician working in a hospital emergency department or hospital urgent care clinic for the purpose of rendering services to unscheduled patients who attend the emergency department or hospital urgent care clinic to receive physician services.

There are specific “H” prefix listings (H1-codes) for consultations and assessments and any physician on duty (regardless of specialty) must submit using these listings.

Admission assessments

Only one admission assessment is eligible for payment per hospital admission. When a patient is transferred from one physician to another physician within the same hospital, an additional admission assessment is not eligible for payment.

Subsequent visits to hospital in-patients

Most subsequent visits are limited as follows:

• First five weeks following admission: Maximum one visit per patient, per day
• Weeks six to 13: Maximum three visits per patient, per week
• After week 13: Maximum six visits, per patient, per month

Other routine visits to hospital in-patients

Additional visits due to intercurrent illness

After five weeks of hospitalization, visits (with the exception of pediatric subsequent visits) are restricted to three visits per week (sixth to thirteenth week of hospitalization) or six visits per month (after the thirteenth week of hospitalization). Assessments in hospital required as a result of an acute intercurrent illness that are in excess of the aforementioned limits, can be claimed as C121 “additional visit due to intercurrent illness.”

Palliative care visits to patients in designated palliative care beds

Palliative care visits to patients are to be claimed using C882 (general/family physician) or C982 (specialist). Unlike the subsequent visit codes, palliative care visits do not have service limits.

Multidisciplinary care

Except where a single service for a team of physicians exists (e.g., the weekly team fee for dialysis), when the complexity of the medical condition requires the services of several physicians in different disciplines, each physician visit constitutes a subsequent visit.

Patient discharge

Patient discharge (C124 subsequent visit – day of discharge), for OHIP payment purposes, refers to a patient who is being discharged from the hospital and not for a patient who is being transferred to another area/ward in the same hospital. This service is also not eligible for payment for patients who have expired in hospital. Since most hospitals require discharge notes as an internal requirement for both transfers within hospital and deceased patients, physicians may mistake this activity as eligible to be paid as C124.

The discharge service is only eligible for payment when:

• The service is rendered by the most responsible physician
• The service occurs at least 48 hours from the patient admission

Most responsible physician codes and premiums

All admission assessments, subsequent visits and palliative care visits are eligible for a premium when rendered by the most responsible physician. Admission assessments may be eligible to be paid with E082 and subsequent visits/palliative care visits may be eligible to be paid with E083 or E084 (the latter for a visit that occurs on a Saturday, Sunday or holiday). Subsequent visits that occur on the two days following the admission assessment have dedicated billing codes; otherwise, physicians are to claim E083 with the subsequent visits codes listed in their respective specialty listing (e.g., general/family practice physicians’ subsequent visit codes are C002, C007 and C009).

Hospitalist premium

Physicians who meet defined service levels for caring for hospital inpatients may be eligible for a premium. The premium is applicable to physicians with specialty 00 (general and family practice) and 13 (internal medicine) based on volume of service encounters and with a minimum of 1,500 core services billed on at least 110 distinct days in the previous fiscal year.

Those meeting the eligibility requirements for the premium will receive a 17 per cent payment on the following qualifying services, with the exception of E082:

• A933A: On-call admission assessment
• C933A: On-call admission assessment
• C002A: Subsequent visit – first five weeks
• C007A: Subsequent visit – weeks six to 13
• C009A: Subsequent visit – after week 13
• C122A: Subsequent visit by the most responsible physician – day following hospital admission assessment
• C123A: Subsequent visit by the most responsible physician – second day following the hospital assessment
• C124A: Subsequent visit by the most responsible physician – day of discharge
• C132A: Subsequent visit – first five weeks
• C137A: Subsequent visit – weeks six to 13
• C139A: Subsequent visit – after week 13
• C142A: First subsequent visit by the most responsible physician following transfer from an intensive care area
• C143A: Second subsequent visit by the most responsible physicianfollowing transfer from an intensive care area
• C882A: Palliative care – GP
• C982A: Palliative care – all other specialties
• E082A: Admission assessment by the most responsible physician premium

Transferral of care vs. referral of care

When a hospital in-patient is referred from one physician to another, the date the second physician assessed the patient for the first time is considered the “admission date” for the purposes of determining the appropriate subsequent visit fee code.

When a hospital in-patient is transferred from one physician to another, subsequent visits by the second physician are calculated based on the actual admission date of the patient.

Critical care

Life-threatening critical care

This service is rendered to a patient with a critical illness or a critical injury, which is one that acutely impairs one or more vital organ(s) causing vital organ system failure as a result of which imminent life-threatening deterioration in the patient’s condition is highly probable.

Examples of vital organ system failure include but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic and or respiratory failure.

Other critical care

The service rendered when a physician provides resuscitation assessment and procedures in an emergency in circumstances other than those described as life-threatening critical care, where there is a potential threat to life or limb of such a type that without resuscitation efforts by the physician, there is a high probability the patient will suffer loss of limb or require life-threatening critical care.

Life-threatening critical care codes G521, G523 and G522 are payable per patient to the first three physicians. Fourth and subsequent physicians should claim payment using G391.

Other critical care codes G395 and G391 are payable per patient to the first three physicians. Services rendered by subsequent physicians are not eligible for payment.

The following services are not eligible for payment when rendered to the same patient by the same physician on the same day as any code describes as life-threatening critical care or other critical care:

• Assessment and ongoing monitoring of the patient's condition
• Intravenous lines
• Cutdowns
• Arterial and/or venous catheters
• Central venous pressure lines
• Endotracheal intubation
• Tracheal toilet
• Blood gases
• Nasogastric intubation with/without anaesthesia with/without lavage
• Urinary catheters
• Pressure infusion sets and pharmacological agents

Special visits

A special visit is one that is initiated by the patient or patient representative (e.g., nurse) for the purpose of rendering a non-elective service. Physicians who make special visits to the hospital are eligible to bill special visit premiums specific to hospital in-patients. Special visits are eligible for payment whether the visit is for a physician’s own patient or for another physician’s patient.

When the physician is on site (i.e., when the travel premium is not eligible for payment) and asked to make a special visit to a hospital in-patient, a special visit premium first person seen code is not eligible for payment when the visit occurs between 7 a.m.-5 p.m., Monday to Friday, unless there has been a sacrifice of office hours.

Read the guide on special visit premiums for more information.

Miscellaneous services

Home care

When completing an application for home-care services, K070 home-care application may be eligible for payment. The completion of the application is eligible for payment only in circumstances where the physician completes the application in whole. K070 is eligible for payment in addition to an assessment fee, where applicable. If patient is already receiving home-care services, K070 is not eligible for payment. K071 or K072 may be eligible for making adjustments to home-care services.

Interviews

An interview with a person who is authorized to make a treatment decision on behalf of the patient in accordance with the Health Care Consent Act may be eligible for payment as K002. This time-based service should be rendered in situations where medically necessary information cannot be obtained from or given to the parent or guardian because of illness, incompetence , etc. The purpose of the interview is not for the sole purpose of obtaining consent nor is the information being obtained a part of the history normally included in the consultation or assessment of the patient.

This time-based service must be a booked, separate appointment to be eligible for payment. Claims should be submitted using the patient’s health number and diagnosis.

Primary mental health care

Primary mental health care (K005) is a time-based service encompassing any combination or form of assessment and treatment by a physician for mental illness, behavioural maladaptations, and/or other problems that are assumed to be of an emotional nature, where there is consideration of the patient’s biological and psychosocial functioning. This code is not to be billed in conjunction with other consultations and visits rendered by a physician during the same patient visit unless there are clearly different diagnoses for the two services.

Hospital in-patient case conference

A case conference is a pre-scheduled meeting, conducted for the purpose of discussing and directing the management of an individual patient. A case conference for an in-patient specifically (K121) requires participation by the physician most responsible for the care of the patient and at least two other participants that include physicians, regulated social workers and/or regulated health professionals regarding a hospital in-patient. A case conference can be conducted by personal attendance, videoconference or by telephone (or any combination thereof).

For a detailed explanation of the payment rules, medical record requirements and time keeping requirements, read the payments for case conference services guide. 

For more details, read the payments for hospital services guide.

'W' Prefix Services

These services apply to patients in chronic care hospitals, convalescent hospitals, nursing homes, homes for the aged and designated chronic or convalescent care beds in hospitals other than patients in designated palliative care beds. In general, when billing for an LTC patient, either a W010 (Monthly Management of a Nursing Home or Home for the Aged Patient) code can be billed or individual W Prefix Codes for services rendered can be billed; but not both. Details will be laid out below.

W010 – Monthly Management of a Nursing Home or Home for the Aged Patient (long-term care)

Monthly Management of a Nursing Home or Home for the Aged Patient is the provision by the most responsible physician (MRP) of routine medical care, management and supervision of a patient in a nursing home or home for the aged for one calendar month. The service requires a minimum of two assessments of the patient each month, where these assessments constitute services described as "W" prefix assessments.

Payment rules

1. Except as outlined in payment rule #8, this service is only eligible for payment once per patient per calendar month
2. This service is only eligible for payment to the MRP
3. When W010 is rendered, none of the services listed as a component of W010 and rendered to the patient by any physician during the month are eligible for payment
4. In the temporary absence of the patient’s MRP (e.g. while that physician is on vacation), W010 remains payable to the patient’s MRP if the service is performed by another physician
5. In the event the MRP renders one "W" prefix assessment in a calendar month and the same physician has rendered W010 to that patient within the previous 11-month period, only that "W" prefix assessment in that month is eligible for payment
6. In the event the MRP renders two, three or four “W” prefix assessments in a calendar month and the same physician has rendered W010 to that patient within the previous 11-month period, only W010 is eligible for payment
7. In the event the MRP renders more than four “W” prefix assessments to the same patient in a month and the same physician has rendered W010 to that patient within the previous 11-month period, any subsequent visits for intercurrent illness rendered by the MRP to the same patient in excess of four in a month are payable as W121 in addition to payment of W010
8. Despite the definition set out above, the requirements of W010 are met when less than two "W" prefix assessments were rendered during the month and/or when the patient was not in the institution for a full calendar month if: a) a patient was newly admitted to the institution and an admission assessment was rendered; or  b) in the event of the death of a patient while in the institution or within 48 hours of transfer to hospital
9. Age-related premiums otherwise applicable to any component service of W010 are not eligible for payment in addition to W010

Once a physician has claimed a W010 service, then W010 must be claimed subsequently going forward. Physicians are not to switch back and forth between billing the W010 and for example the W003 and W008. If a physician does not want to claim W010 for a specific patient, then they must begin by billing the other W Prefix Codes, such as the W003 and W008, from the onset of services being rendered.

Usually, the service requires a minimum of two assessments of the patient each month, however, if a physician only performs one subsequent visit in the month but has otherwise claimed a W010 in the previous 11 months, then the single subsequent visit is payable as a W010 in that month. If the physician has performed two, three or four subsequent visits in a particular month and has claimed at least one W010 in the preceding 11 months, only W010 is payable. However, if the physician performs a subsequent visit in excess of four in a month and has claimed W010 in the preceding 11 months, then the visits in excess of four may be payable as W121 if the visit(s) were for intercurrent illness. W121 must be submitted for manual review.

Effective April 1, 2013, W010 is being paid at nil to physicians in the FHN/FHO groups who have regularly enrolled patients (Q200) that reside in a long-term care (LTC) facility. The rejected claims show on the RA with the explanation code “EQP – Enrolment type not eligible.” To continue receiving W010, the affected physician groups must either enrol these patients as LTC patients (using a Q202), or de-enrol them and provide care on a fee-for-service basis.

Admission Assessments, Subsequent Visits, and Ongoing Care in LTC if not billing the W010 monthly management fee code:

These codes below are included in the monthly management fee, W010, and cannot be billed in addition to it (except if the conditions described in payment rule #7 above in relation to the W121 is satisfied). If a physician chooses not to bill the W010 code, then visits can be billed as appropriate from the W-Prefix codes listed. For example, a physician can bill an appropriate Admission Assessment on admission to LTC, and then the appropriate subsequent visit codes can be billed for services rendered. 

Admission Assessments

W102 – Type 1 Admission Assessment: A general assessment rendered to a patient on admission.  

W104 – Type 2 Admission Assessment: Applies when the admitting physician makes an initial visit to assess the condition of the patient following admission and has previously rendered a consultation, general assessment or general reassessment of the patient prior to admission.  

W107 – Type 3 Admission Assessment: Is a general re-assessment of a patient who is re-admitted to the long-term care institution after a minimum three-day stay in another institution.

Subsequent visits

A subsequent visit is any routine assessment following the patient’s admission to a long-term care Institution.  

W003 – first two subsequent visits per patient per month

W008 – additional subsequent visits (maximum two per patient per month)  

Death in LTC

For pronouncement of death in an LTC facility (regardless of type of facility) with completion of the death certificate, physicians are to bill W777 and for completion of the death certificate alone, bill W771 (subject to the same conditions as A777).

Special considerations

Death in LTC

When pronouncement of death requires a special visit then general listing fees would apply (A777) in addition to the Special Visit Premium. This can be billed in addition to the W010. An Electronic Medical Certificate of Death can be billed for using A771 with no special visit premium applicable. This can be billed in addition to the W010.

W Prefix Codes and FFS cap for physicians in a FHO

Only FHO in-basket services to non-enrolled patients will count toward the FHO FFS limit. The majority of W-Prefix codes are out of the basket and as such do not contribute to the hard cap. 

On Call Funding

This is not an OHIP-paid service. Funding is provided to each long-term care home under the “Physician on-call program” and is based on the number of licensed and approved beds in operation at the home as of January 1 of each funding year.

Any in-year changes to bed counts, approved under the act, may result in prorated funding adjustments as determined by the Ministry of Health. 

Palliative care

Palliative care is defined in the OHIP Schedule of Benefits as “care provided to a terminally ill patient in the final year of life where the decision has been made that there will be no aggressive treatment of the underlying disease and care is to be directed to maintaining the comfort of the patient until death occurs.”

Several palliative care codes can be billed for palliative patients in LTC. In general, palliative care case management G512 can billed weekly in addition to K Prefix Codes as the conditions for the services are met. For physicians not billing the W010 (Monthly Management of a Nursing Home or Home for the Aged Patient) fee code, there are also W Prefix subsequent visit codes that can be billed.

G512 – Palliative Care Case Management

This is a service rendered for providing supervision of palliative care to a patient for a period of one week, commencing at midnight Sunday, and includes the following specific elements.

1. Monitoring the condition of a patient including ordering tests and interpreting test results
2. Discussion with and providing telephone advice to the patient, patient’s family or patient’s representative even if initiated by the patient, patient’s family or patient’s representative
3. Arranging for assessments, procedures or therapy and coordinating community and hospital care including but not limited to urgent rescue palliative radiation therapy or chemotherapy, blood transfusions, paracentesis/thoracentesis, intravenous or subcutaneous therapy
4. Providing premises, equipment, supplies and personnel for all elements of the service

Payment rules

1. The service is only eligible for payment when rendered by the physician most responsible for the patient’s care, or by a physician substituting for this physician
2. G511, K071 or K072 are not eligible for payment to any physician when rendered during a week that G512 is rendered
3. G512 is limited to a maximum of one per week (Monday to Sunday inclusive) per patient and, in the instance a patient is transferred from one most responsible physician to another, is only eligible for payment to the physician who rendered the service the majority of the week
4. In the event of the death of the patient or where care commences on any day of the week, G512 is eligible for payment even if the service was not provided for the entire week

G511 – Telephone Management of Palliative Care

The provision by telephone of medical advice, direction or information at the request of the patient, patient’s relative(s), patient’s representative or other caregiver(s), regarding a patient receiving palliative care at home. The service must be rendered personally by the physician and is eligible for payment only when a dated summary of the telephone call is recorded in the patient’s medical record.  

Payment rules

1. This service is limited to a maximum of two services per week
2. This service is not eligible for payment if rendered the same day as a consultation, assessment, time-based service or other visit by the same physician
3. This service is not eligible for payment if a claim is submitted for K071 or K072 for the same telephone call
4. This service is only eligible for payment when rendered by the physician most responsible for the patient’s care or by a physician substituting for this physician

W882/W872 – Palliative Care Subsequent Visits

A subsequent visit is any routine assessment following the patient’s admission to a long-term care institution. The applicable palliative care subsequent visit code depends on the type of facility. For visits to patients in a Chronic Care or Convalescent Hospital, GPs are eligible for W882. For visits to patients in a Nursing home or home for the aged, GPs are eligible for W872.

W872 is not eligible for payment when the W010 (Monthly Management of a Nursing Home or Home for the Aged Patient) fee code is being billed in the same month.

K023 – Palliative Care Support

Palliative care support is a time-based service payable for providing pain and symptom management, emotional support and counselling to patients receiving palliative care.

Payment rules

1. With the exception of A945/C945, any other services listed under the "Family Practice & Practice in General" in the "Consultations and Visits" section of the Schedule are not eligible for payment when rendered with this service
2. Start and stop times must be recorded in the patient's permanent medical record or the service will be adjusted to a lesser paying fee
3. When the duration of A945 or C945 exceeds 50 minutes, one or more units of K023 are payable in addition to A945 or C945, provided that the minimum time requirements for K023 units occur 50 minutes after the start time for A945 or C945
4. This service is claimed in units. Unit means ½ hour or major part thereof – see General Preamble GP7, GP55 for definitions and time-keeping requirements.

Details surrounding time units for K023 can be seen in the following section.

Case Conferences, Interviews and Counselling

These codes are billed based on time units and require documentation of a start and stop time.

Case Conferences

A case conference is a pre-scheduled meeting, conducted for the purpose of discussing and directing the management of an individual patient. It must be conducted by personal attendance, videoconference or by telephone (or any combination thereof).

Payment rules

1. A case conference is only eligible for payment if the physician is actively participating in the case conference, and the physician’s participation is evident in the record
2. A case conference is only eligible for payment in circumstances where there is a minimum of 10 minutes of patient-related discussion
3. A case conference is only eligible for payment if the case conference is pre-scheduled.
4. Any other insured service rendered during a case conference is not eligible for payment
5. A case conference is not eligible for payment in circumstances where the required participants necessary to meet the minimum requirements of the case conference service receive remuneration, in whole or in part, from the physician claiming the service
6. The case conference is not eligible for payment to a physician who receives payment, other than by fee-for-service under this Schedule, for the preparation and/or participation in the case conference
7. Where payment for a case conference is an included element of another service, services defined as case conferences are not eligible for payment

Medical record requirements

A case conference is only eligible for payment where the case conference record includes all of the following elements:

1. Identification of the patient
2. Start and stop time of the discussion regarding the patient
3. Identification of the eligible participants
4. The outcome or decision of the case conference

One common medical record in the patient's chart for the case conference signed or initialled by all physician participants (including listing the time the service commenced and terminated and individual attendance times for each participant if different) would satisfy the medical record requirements for billing purposes.

K124 – Long-term care/CCAC case conference

For this type of care conference there is a requirement for participation by the physician most responsible for the care of the patient and at least two other participants that include physicians, regulated social workers, employees of a CCAC and/or regulated health professionals regarding a long-term care institution inpatient.

Payment rules

1. K124 is limited to a maximum of four services per patient, per physician, per 12-month period
2. A maximum of eight units of K124 are payable per physician, per patient, per day
3. K124 is not eligible for payment for radiation treatment planning services listed in the Radiation Oncology section of the Schedule of Benefits
4. Services described in the supervision of postgraduate medical trainees section of the Schedule of Benefits are not eligible for payment as K124

K705 – Long-term care – high risk patient conference

This type of care conference risk requires the participation by a physician and at least two other participants that include physicians, employees of a CCAC, regulated social workers and/or regulated health professionals regarding a long-term care institution high-risk inpatient. A high-risk patient is a patient identified by staff in the long-term institution with clinical instability based on a change in the Resident Assessment Instrument – Minimum Data Set (RAI-MDS) for Nursing Homes.

Payment rules

1. K705 is limited to a maximum of four services per patient, per physician, per 12-month period
2. A maximum of eight units of K705 are payable per physician, per patient, per day
3. K705 is not eligible for payment for radiation treatment planning services listed in the Radiation Oncology section of the Schedule of Benefits
4. Services described in the supervision of postgraduate medical trainees section of the Schedule of Benefits are not eligible for payment as K124

Interviews

Interviews are for obtaining information from, engaging in discussion with, and providing advice and information to interviewee(s) on matters related to the patient’s condition and care. Interviews are not eligible for payment when the information being obtained is part of the history normally included in the consultation or assessment of the patient. The interview must be a booked, separate appointment lasting at least 20 minutes. Unit means ½ hour or major part thereof.

K002 – Interviews with relatives or a person who is authorized to make a treatment decision on behalf of the patient in accordance with the Health Care Consent Act

Payment rules

1. K002 is only eligible for payment if the physician can demonstrate that the purpose of the interview is not for the sole purpose of obtaining consent

Counselling is a patient visit dedicated solely to an educational dialogue with a physician. This service is rendered for the purpose of developing awareness of the patient’s problems or situation and of modalities for prevention and/or treatment, and to provide advice and information in respect of diagnosis, treatment, health maintenance and prevention.

Individual counselling is counselling rendered to a single patient. The patient must have a pre-booked appointment as otherwise the claim for the service will be paid at the lesser assessment fee. These are billed as units and unit means ½ hour or major part thereof.

K013 – Individual Care (first three units per year)

There is a limit of three units (individual or group counselling) per patient per physician per year at this higher fee.  

K033 – Individual Care (additional units)

Bill this for additional units beyond the first three units (individual or group counselling) per patient per physician per year at this lesser fee.  

K005 – Primary Mental Health Care

Services encompassing any combination or form of assessment and treatment by a physician for mental illness, behavioural maladaptations and/or other problems that are assumed to be of an emotional nature, where there is consideration of the patient’s biological and psychosocial functioning.

K015 – Counselling of relatives – on behalf of catastrophically or terminally ill patient

Counselling of relatives on behalf of a catastrophically or terminally ill patient is counselling rendered to a relative or relatives or representative of a catastrophically or terminally ill patient, for the purpose of developing an awareness of modalities for treatment of the patient and/or his or her prognosis.

The claim must be submitted under the health number of the patient who is catastrophically or terminally ill.

Eligible Primary Care Bonuses

Physicians participating in Patient Enrollment Models (PEMs) may be eligible to receive the annual Palliative Care Special Premium and/or the LTC Special Premium paid directly by OHIP, once certain thresholds are reached.

There are two threshold levels: Level 1 is for all eligible physicians including PEMs and Level 3 is for eligible PEM physicians only.

Rostered vs Non-rostered LTC Patients

Rostered LTC patient

For each patient rostered, the physician receives a base rate (not age and sex adjusted) of $1,223.22. In addition to the base rate, LTC patients qualify for a 20.65 per cent access bonus.  Physicians will also receive 19.41 per cent shadow billing on the fee value of W010 ($115.25). In a scenario where a physician bills only W010 for their rostered LTC patient for a 12-month period: $1,223.22 + (19.41 per cent x 12 x $115.25) = $1,491.66 per patient and a potential maximum of 20.65 per cent x $1,223.23 (i.e., maximum of $252.59) for access bonus.

Non-rostered patient

In a scenario where a physician bills only W010 for their non-rostered LTC patient for a 12-month period: 12 x $115.25 = $1,383.00 per patient.

Special Visit Premiums

Visits to LTC are often eligible to be billed with special visit premiums (SVPs) when a visit is initiated by a patient or an individual on behalf of the patient for the purpose of rendering a non-elective service. Regardless of the time of day at which the service is rendered, special visit premiums are not eligible for payment for patients seen during rounds at a hospital or long-term care institution (including a nursing home or home for the aged). Likewise, SVPs may not be claimed in conjunction with visits to a LTC facility to admit patients on an elective basis.

SVPs have three components: (1) the travel premium, (2) the first person seen premium, and (3) an additional person seen premium (where applicable). Each component of the special visit premium is separately billable and is to be claimed in conjunction with an “A” prefix assessment code, based on the type of service rendered. As an example, if a physician was called in to see a patient in a LTC facility on the weekend, then the appropriate OHIP submission would consist of two “W” prefix SVPs (W963 travel and W998 patient premiums) + the applicable “A” prefix assessment fee (e.g. A777).

Telephone/E-Consultation and Virtual Care

Telephone/E-Consult

K730 – Physician-to-physician telephone consultation – referring physician

Physician-to-physician telephone consultation is a service where the referring physician or nurse practitioner, in light of his/her professional knowledge of the patient, requests the opinion of a physician (the “consultant physician”) by telephone who is competent to give advice in the particular field because of the complexity, seriousness, or obscurity of the case.

The referring physician/NP initiates the telephone consultation with the intention of continuing the care, treatment and management of the patient. When the purpose of the telephone discussion is to arrange for transfer of the patient’s care to any physician, the service is not eligible for billing. A record of the consultation must be kept by the physician(s) who submits a claim for the service. The services are only eligible for payment when a minimum of 10 minutes of patient-related discussion for any given patient has occurred.

K738 – Physician-to-physician telephone consultation – referring physician

Physician-to-physician e-consultation is a similar service to the physician/NP-to-physician telephone consultation except that both the request and opinion are sent by electronic means through a secure server.

This service is only eligible for payment if the consultant physician has provided an opinion and/or recommendations for patient treatment and/or management within thirty (30) days from the date of the e-consultation request.

Virtual Care

Virtual Care Services are not eligible for payment for services provided to hospital inpatients or patients in a long-term care institution unless all of the following requirements have been met:

• The physician providing the service is not the patient's MRP
• The hospital/long-term care institution does not have a physician on staff and present in the community with the expertise to render the necessary service, as documented by the referring physician in the patient’s medical record
• An assessment with a direct physical encounter by the referring physician must have been completed within 30 days preceding a virtual in-patient specialist consultation to confirm the need for a consultation

Read more in the long-term care services guide.

Initial assessment for eligibility

When a physician provides the initial assessment of the patient to ensure they meet eligibility criteria for medical assistance in dying, the fee code that best describes the service rendered is the one that should be billed.

For example, if the patient is already in the care of the physician, then possible fees could be counselling (e.g., K013 individual counselling), primary mental health (K005), an assessment fee (e.g., specific, intermediate or partial assessment) or palliative care support (K023).

If the patient was referred from another physician or nurse practitioner, then a consultation fee would likely be applicable. In situations where considerable time is taken to render the consultation, then K001 detention may be eligible for payment in addition to the consultation fee or, alternatively, K023 when A945 special palliative care consultation is billed and time requirements are met (e.g., K023 is eligible for payment with A945 when duration of the consult exceeds 50 minutes). In circumstances where a referring physician billing number is not available, then K023 may be claimed. Physicians should refer to their specialty general listings for the consultation fee that best describes the service provided, as some specialties have consultation fees that are time-based (e.g., special and comprehensive consultations).

For payment criteria, including time requirements for K001 detention, please refer to the OHIP Schedule of Benefits.

Independent second assessment for eligibility

When a physician provides the second independent assessment of the patient to ensure eligibility criteria for medical assistance in dying is met, the physician must be independent of the first assessing physician or nurse practitioner and must provide a written opinion confirming whether the patient meets the requisite criteria for medical assistance in dying.

In most cases, the appropriate fee for rendering the independent second assessment for eligibility is a consultation fee. In situations where considerable time is taken to render the consultation, then K001 detention may be eligible for payment in addition to the consultation fee or K023 when A945 special palliative care consultation is billed and time requirements are met. 

Procedural planning and case management

For discussions with other health-care providers (e.g., other physicians, pharmacist, coroner, CCAC) involved in the management of an individual patient’s medical assistance in dying request (e.g., procedural planning), palliative care support (K023) fee is eligible for payment for the duration of time spent. The total time represents the cumulative time of all discussions on that day pertaining to the same patient. The minimum cumulative time requirements (20 minutes for the first unit) must be met for the day before K023 can be billed. The patient’s medical record should indicate the name(s) of the health-care providers and the start and stop times of the discussion(s). The claim should also be flagged within the applicable billing software when submitted for payment to indicate payment is for the provision of medical assistance in dying.

Please note that there is no fee eligible for payment for procedural debriefing; this is a quality assurance and learning process, similar to mortality rounds in a hospital or elsewhere, which also do not have fees billable to OHIP.

Provision of MAID

Palliative care support (K023) should be claimed for the duration of time spent on the provision of medical assistance in dying. This includes travel time spent picking up and returning any drugs used in the provision of medical assistance in dying, and continues with time spent with the patient and family, obtaining final consent, drug administration, pronouncement and certification of death, counselling of relatives as necessary, meeting reporting requirements and notification of the coroner’s office.

If administration of the fatal dose of medication is by intravenous, then G379 can be billed for insertion of the IV.

A maximum of two physicians are eligible to be paid K023 for the provision of medical assistance in dying. Medically necessary services provided by physicians other than the physician(s) providing the MAID service rendered to the patient on the day of the provision of medical assistance in dying, are eligible for payment.

Travel to patient’s home

Travel for an assessment or for the provision of medical assistance in dying should be claimed using K023. As travel time can be claimed using K023, special visit premiums are not payable.

More information, including a table summarizing key points, can be found in the MAID quick reference guide.

While many patients receiving palliative care are dying of cancer, palliative care is a service that could be rendered to patients who are dying of any number of chronic or terminal illnesses (e.g., AIDS, heart disease, muscular dystrophy, etc.).

Not every patient will require or be eligible for palliative care services in their final year of life. For example, a patient residing in a long-term care facility may be nearing the end of their life, but not dying of a terminal illness requiring comfort measures.

Special palliative care consultation

A special palliative care consultation is a consultation requested because of the need for specialized management for palliative care where the physician spends a minimum of 50 minutes with the patient and/or patient’s representative/family in consultation (the majority of the time must be spent in consultation with the patient). In addition to the general requirements for a consultation, the service includes a psychosocial assessment, comprehensive review of pharmacotherapy, appropriate counselling and consideration of appropriate community services, where indicated.

When the duration of a special palliative care consultation (A945 or C945) exceeds 50 minutes, one or more units of palliative care support (K023) are eligible for payment in addition to A945 or C945, provided that the minimum time requirements for K023 are met. Start and stop times must be recorded in the patient’s permanent medical record.

In cases where the palliative care consultation does not meet the minimum 50-minute time requirement, then a regular consultation fee may be eligible for payment (A005, C005 or W105).

Palliative care case management fee (G512)

The palliative care case management fee is a payment for a service rendered for providing supervision of palliative care to a patient for a period of one week, commencing at midnight Sunday, and includes the following specific elements:

• Monitoring the condition of a patient, including ordering tests and interpreting test results
• Discussion with and providing telephone advice to the patient, patient’s family or patient’s representative(s), even if initiated by the patient, patient’s family or patient’s representative(s)
• Arranging for assessments, procedures or therapy and co-ordinating community and hospital care, including but not limited to urgent rescue palliative radiation therapy or chemotherapy, blood transfusions, paracentesis/thoracentesis, intravenous or subcutaneous therapy
• Providing premises, equipment, supplies and personnel for all elements of the service

Payment rules that apply to the fee include:

• The service is only eligible for payment when rendered by the physician most responsible for the patient’s care, or by a physician substituting for this physician
• G511, K071 or K072 are not eligible for payment to any physician when rendered during a week that G512 is rendered
• G512 is limited to a maximum of one per week (Monday to Sunday inclusive) per patient, and, in the instance a patient is transferred from one most responsible physician to another, is only eligible for payment to the physician who rendered the service the majority of the week
• In the event of the death of the patient or where care commences on any day of the week, G512 is eligible for payment even if the service was not provided for the entire week

Download the reference guide for more information on payments for palliative care.

Cervical screening – periodic testing (G365)

Screening for cervical cancer via a Pap smear is eligible for payment every three years (33 months), for patients 21-70 years of age. Testing for patients over the age of 70 is uninsured when the patient has had three or more normal tests in the previous 10 years.

While the current guidelines recommend routine Pap screening once every 36 months, the OHIP Schedule period defines the limit as “one per patient, per 33 month period” in recognition that some patients may be seen just prior to the recommended time interval.

If G365 is performed outside of hospital, physicians are eligible for an additional fee (E430).

Followup cervical screening (G394)

Pap smear testing performed outside of regular screening is payable for certain indications:

• In followup of an abnormal Pap smear
• In followup of an inadequate Pap smear
• On an annual basis for patients who are immunocompromised, e.g., HIV-positive or taking long-term immunosuppressants
• For a patient with a history of oncogenic HPV-typing
• Where the physician is of the opinion that the patient is a member of a vulnerable group that may have difficulty accessing the services within the specified time period

Physicians who claim G394 must have documentation of an abnormal or inadequate Pap result for which a followup is required, documentation of the cause of the immunocompromised status or documentation of difficulties in accessing the service within the specified time period. G394 is not eligible for payment in the absence of the required documentation.

If G394 is performed outside of hospital, physicians are eligible for an additional fee (E431).

Pap smear in addition to an assessment

When a pelvic examination is a normal part of the following service, it is an included element and is not separately billable:

• Consultation
• Repeat consultation
• General assessment
• General re-assessment
• Specific assessment
• Specific re-assessment
• Routine post-natal visit

Though physicians cannot claim G365 or G394 with the services listed above, if the service was performed outside of hospital, the additional fee (E430 or E431) is eligible for payment. E430 represents a periodic Pap smear whereas E431 represents an additional Pap smear for the indications applicable to G394.

For example, if a family physician performs a periodic Pap smear, outside hospital, as part of a general assessment (A003), the appropriate codes to claim are A003 and E430.

If the Pap smear is performed in conjunction with any assessments not listed above, the physician is eligible to be paid the appropriate assessment fee and G365 or G394, and the corresponding additional fee for services performed outside hospital.

Examples of assessments where G365 and G394 are separately billable include:

• Minor assessment
• Intermediate assessment
• Periodic health visit – adult age 18 to 64 inclusive
• Periodic health visit – adult 65 years of age and older

Pap smear – sole procedure

In circumstances where the Pap smear is the sole reason for the patient visit, G700, the basic fee-per-visit premium is eligible for payment.

For example, if a patient presents for a repeat Pap smear due to a previous inadequate Pap smear and the requirements for any assessment have not been met, the appropriate codes to claim are G394, E431 and G700.

Pap smear as an uninsured service

Periodic Pap smears in excess of the limit (once per patient, per 33 months) are not insured services. In a situation where a patient requests a Pap smear more frequently than the interval recommended by CCO and paid for by OHIP, the patient is responsible for the cost of the test.

Intended use of G365/G394 and E430/E431

The Pap smear tests are intended for cervical cancer screening only. In situations where physicians are performing an internal exam for other reasons (e.g., suspicion or presence of a sexually transmitted infection, pelvic pain, menstrual changes, a friable lesion, etc.), and are required to use a speculum, the Pap smear code and/or additional payment for services performed outside hospital (E430 or E431) are not eligible for payment.

Read the Pap smear reference guide for more information.

After-hours premium fees

Q012A/Q016A: After-hour fees

• No claims for premiums may be made for services rendered between 8 a.m.- 5 p.m.
• The after-hours premiums may be billed for enrolled patients seen during regular after-hour services held after 5 p.m. on weekdays or any time on weekends or statutory holidays
• The services must be available to scheduled and non-scheduled patients. The services must be held during regularly scheduled times and the physician must make his/her patients aware of the dates and times such services are available
• Premiums should not be billed for patients who are seen after 5 p.m. because the physician’s clinic is behind schedule nor is it the intention for physicians to alter regular daytime hours solely for the purpose of billing 
• Physicians must be available during regular office hours to provide comprehensive care to their patients. This obligation is specified in the FHG and FHO and other agreements

Payment rules

Physicians can receive a 30 per cent premium on the value of the following fee codes: A001A, A003A, A004A, A007A, A008A, A888A, K005A, K013A, K017A, K030A, K033A, K130A, K131A, K132A and Q050. In order to receive that after-hour premium, the Q012A or Q016A must be submitted.

Newborn care fees

Q014A/Q015A: Newborn care episodic fee

The Q014A and Q015A are premiums that are received for each well-baby visit, up to a maximum of eight per patient, to enrolled patients in the first year of life. These codes may only be billed with a valid A007A intermediate assessment code. If it is billed in conjunction with any other service, it will result in a rejected claim that will appear on a claims error report with reject code “AD9 – not allowed alone.”

Payment rules

The Q014/Q015 and A007A must have the same service date and the service date must be before the patient’s first birthday. If it is billed with an A007A assessment that does not have the same service date, it will be rejected and appear on your claims error report with a rejection code “A2A – outside of age limit.”

If a subsequent enrolment for the patient is processed in the following 12-month period, the code will be automatically reprocessed for payment, providing the service date of the code is on or after the patient’s signature date on the enrolment/consent form.

Serious mental illness bonus

Q020A/Q021A: Serious mental illness fee

The serious mental illness premium is an annual bonus for providing comprehensive primary care to a minimum of five enrolled patients with diagnoses of bipolar disorder and/or schizophrenia. Fee Schedule codes for services provided to these patients must be accompanied by tracking code Q021A for schizophrenia and tracking code Q020A for bipolar disorder, and the patient must be rostered in order for the premium to be paid.

For physicians in a FHG, the schizophrenia bonus is tracked by submitting the diagnostic code 295 along with the service fee code.

Payment rules

These codes are paid during the fiscal year and will be included in the special premium payment, which is reported on the monthly remittance advice as an accounting transaction with the text line. The minimum service level is five patients for level one and an additional five patients for level two.

Q020A and services with diagnostic code 295 that are submitted for patients that are not formally enrolled with the billing physician will be processed but will not be counted towards the serious mental illness premium. If a subsequent enrolment for the patient is processed in the following 12-month period, the Q020A and/or any services with diagnostic code 295 provided after enrolment will automatically be included towards the cumulative count for this premium.

New unattached patient fees

Q200A: Per patient rostering fee code

Q200 is a per patient rostering fee code that is billed at $0. This fee code must be submitted to the Ministry of Health when a patient is enrolled with the physician as it triggers enrolment in their system.

Submission rules

As of Feb. 1, 2013, physicians are no longer required to send the enrolment/consent form to the ministry, but must keep in office for record keeping. The service date for the Q200 must be the date on the enrolment/consent form.

Eligible models

CCM, FHG, FHN, FHO, RNPGA, BSM, SJHC, SEAMO and WHA

Q202A: Long-term care per patient rostering fee code

Q202 is a long-term care per patient rostering fee code that is billed at $0. This fee code must be submitted to the Ministry of Health when a long-term care patient is enrolled with the physician as it triggers enrolment in their system.

Submission rules

As of Feb. 1, 2013, physicians are no longer required to send the enrolment/consent form to the ministry, but must keep in office for record keeping. The service date for the Q202 must be the date on the enrolment/consent form.

Eligible models

FHN and FHO only

Q023A: New unattached patient fee – from hospital

Q023A may be claimed for enrolling a new unattached patient who had an acute care hospital in-patient stay within the previous three months. The service date of a Q023A claim must be the same as the date on the enrolment/consent form and the declaration form.

Fee: $150

Payment rules

There are no limits on the number of Q023A a physician can claim. This fee is restricted to patients who at the time of enrolment did not have a family physician and had an acute care in-patient stay within the previous three months. A physician may submit both Q023A and a per patient rostering fee code (Q200A) for the same patient.

For any individual patient a physician may only claim an unattached patient fee. Both the unattached patient (or parent/legal guardian where applicable) and the enrolling physician must complete both the Patient Enrolment and Consent to Release Personal Health Information form and the Unattached
Patient Declaration form.

Newborns qualify as unattached patients if they meet the following two criteria:

• The mother does not have a family physician
• The newborn has been admitted to a Level II or higher Neonatal Intensive Care Unit within the past three months. If a Level II bed is not available, a newborn who meets the criteria for a Level II nursery but is cared for in a Level I nursery would qualify. Typically, the discharge summary for these babies would indicate a diagnosis other than healthy newborn

Eligible models

CCM, FHG, FHN, FHO, RNPGA, BSM, GHC, SJHC, SEAMO and WHA

Q043A: New patient fee abnormal/increased risk of colorectal cancer

As part of the ColonCancerCheck program, Cancer Care Ontario is collecting and maintaining a referral list of physicians who are currently accepting new patients with an abnormal FIT result or at increased risk of colorectal cancer (CRC).

Patients without a family physician can request a FIT through Telehealth Ontario by calling (Toll-free: 1-866-828-9213 or Toll-free TTY: 1-866-797-0007).

The patient will complete the FIT and mail it to the laboratory for processing in the postage prepaid envelope or drop it off at a LifeLabs specimen collection centre.

For patients without a family physician and when normal results are obtained, the ColonCancerCheck program will send a letter to the patient informing them of the results and to return for screening in two years’ time.

For patients without a family physician and when abnormal results are obtained, the program will contact a physician from the referral list to arrange an appointment for followup care (e.g., referral to colonoscopy).

Fees: $150 for patients up to and including 64 years of age, $170 for patients 65 to 74 years of age, and $230 for patients 75 years of age and older

Payment rules

To be eligible for the new patient fee abnormal/increased risk colorectal cancer fee, the physician and patient will complete and sign a Patient Enrolment and Consent to Release Personal Health Information form and a New Patient Declaration form. The patient is given a copy of the enrolment/consent form and the physician retains a copy of both forms for practice records. 

If a physician’s software program does not support multiple amounts for the same fee code, the physician may bill the Q043A for $150 and the ministry’s system will adjust it accordingly.

The service date of a Q043A claim must be the same as the date on the enrolment/consent form and the declaration form.

There is no annual limit on the number of services (Q043A) a physician is eligible to claim.

Eligible models

CCM, FHG, FHN, FHO, RNPGA, BSM, GHC, SJHC, SEAMO and WHA

Q053A: New unattached patient fee – HCC complex/vulnerable patient

Q053A is a one-time payment of $350 for enrolling a complex/vulnerable patient through the Health Care Connect Program.

Fee: $350

Payment rules

It is the same payment amount regardless of the age of the patient. This code requires the patient to be registered with Health Care Connect as a complex/vulnerable patient. The patient must be enrolled with the physician within three months of being registered with Health Care Connect and must be deemed a complex vulnerable patient by Health Care Connect to be able to bill this fee code.

Eligible models

CCM, FHG, FHN, FHO, RNPGA, BSM, GHC, SJHC, SEAMO and WHA

Chronic disease management fees

Q040A: Diabetes annual flow sheet fee

Q040A can be paid for an enrolled or non-enrolled diabetic patient once per year. This requires completion of a flow sheet to be maintained in the patient’s record that includes the required elements of diabetes management and complication risk assessment consistent with the Canadian Diabetes
Association. It is intended that the flow sheet be completed over the course of the year to support a planned care approach to diabetes management.

Fee: $60

Payment rules

Q040 is only eligible for payment if the physician has rendered a minimum of three K030 services for the same patient in the same 12-month period to which the Q040 service applies.

The code may be submitted separately or in combination with other fee schedule codes. If a second Q040A is submitted for a patient within 365 days of a previously processed Q040A for the same patient by the same physician, the second Q040A will be processed at $0 with an explanatory code “M1 –
maximum fee allowed for these services has been reached.” If the second Q040A is submitted by a different physician, the second Q040A will be rejected to the daily claims error report with the error code “A36 – claimed by other pract.” If a physician submits a Q040A but does not have “billing specialty 00 – family practice and practice in general,” the claim will reject with the error code “AD4 – ineligible specialty.”

Eligible physicians

FFS, CCM, FHG, FHN, FHO, RNPGA, BSM, GHC, SJHC, SEAMO and WHA

Q042A: Smoking cessation counselling fee

Q042A is an additional fee for physicians who provide a dedicated followup counselling session with their enrolled patients who have committed to quit smoking.

Fee: $7.50

Payment rules

A physician is eligible to receive per year payment for a maximum of two followup Q042A smoking cessation counselling fees if:

• The physician had previously billed a valid initial add-on smoking cessation fee (E079A) claim
• The K039 fee code is billed in the 12 months following the service date of a valid E079 claim

Note: In models that have group enrolment, a physician is eligible to submit and receive payment for Q042A for patients affiliated to him/her by virtue of the physician’s acknowledgement on the enrolment/consent form.

Eligible models

CCM, FHG, FHN, FHO, RNPGA, BSM, GHC, SJHC, SEAMO and WHA

Q050A: Heart failure management incentive fee

Q050A is a $125 annual payment available to physicians for co-ordinating, and documenting all required elements of care for enrolled heart failure patients. This requires completion of a flow sheet to be maintained in the patient’s record that includes the required elements of heart failure management consistent with the Canadian Cardiovascular Society recommendations on heart failure.

Physicians may choose to use the heart failure patient care flow sheet or one similar to track a patient’s care. It is intended that the flow sheet be completed over the course of the year to support a planned care approach for heart failure management.

Fee: $125

Payment rules

A physician is eligible to submit for the CHF management incentive annually for an enrolled heart failure patient once all the required elements of the patient’s heart failure care are documented and complete.

The flow sheet must track the following: comprehensive physical examination, laboratory monitoring of Na+, K+, serum creatinine and eGFR, patient education for modifiable risk factor reduction and self management, pharmacologic management for appropriate use of first-line, and symptom relief and preventive medications.

Eligible models

CCM, FHG, FHN, FHO, RNPGA, BSM, GHC, SJHC, SEAMO and WHA

FIT preventive care fees and bonuses

Q150A: Colorectal cancer screening fee

Physicians no longer need to maintain an inventory of, or distribute colorectal cancer screening tests (i.e., gFOBT). Instead, physicians will submit requisitions to LifeLabs (e.g., by fax or certified electronic medical record), and LifeLabs will mail FIT kits directly to their patients. Physicians will bill the existing Q150A for counselling the patient on screening and the use of the FIT and for completing and submitting the requisition to LifeLabs.

Fee: $7

Payment rules

To claim the fee the physician must:

• Discuss and assess the patient’s medical and family history and eligibility to determine if the FIT is appropriate for the patient
• Confirm the patient’s date of birth and address for the FIT kit
• Educate the patient during an office visit on the correct use of the FIT kit
• Submit the completed FIT requisition form to LifeLabs (e.g., by fax 1-833-676-1427 or certified electronic medical record)
• The Q150A fee code is billable for patients at average risk of developing colorectal cancer, ages 50 to 74 years
• The Q150A fee code is billable for all patients enrolled and non-enrolled
• The Q150A fee code is limited to a maximum of one service per patient every 730-day period
• When a second Q150A code is billed for a single patient by any other provider in the same 730-day period, the Q150A will pay $0 and have the explanation code M4 “maximum fee allowed for these services by one or more practitioners has been reached” applied to the claim

Eligible models

All family physicians in Ontario, including physicians participating in patient enrolment models, are eligible.

Q152A: Colorectal cancer screening test completion fee

Q152A is a fee available to family physicians in Ontario to be submitted once the patient’s once the patient’s FIT results have been reviewed by the physician and communicated to the patient. Q152A may be billed once per patient per two years.

Physicians participating in patient enrolment models who are eligible to receive the preventive care bonus fees (Q100A-Q123A) are not eligible to claim Q152. FHG and CCM physicians are not eligible to claim Q152 except where the FHG/CCM physician is identified as new graduates and have not met the minimum roster size of 450 enrolled patients, or the FHG/CCM physician roster size is less than 650 enrolled patients.

Fee: $5

Payment rules

Q152A can only be billed once per patient two years.

Eligible models

Physicians participating in patient enrolment models who are eligible for preventive care bonus payment are not eligible to bill this fee code.

FHG and CCM physicians identified as new graduates will be eligible when they have not met the minimum roster size of 450 enrolled patients. As well, all other FHG and CCM physicians will be eligible when their roster sizes are less than 650 enrolled patients.

Family physicians who are not in one of the patient enrolment models are eligible to claim this fee code.

Q590: Basic flu shot fee-per-visit premium

The Q590A basic flu shot fee-per-visit premium is payable under the Family Health Network and Family Health Organization contracts for the provision of influenza vaccination where the provision of the influenza vaccine is the sole reason for the visit. FHN and FHO physicians may submit Q590A basic flu shot fee-per-visit premium FHN/FHO fee in conjunction with G590 influenza vaccinations for the flu season.

Fee: $5.10

Payment rules

The Q590A is payable for enrolled and non-enrolled patients. If it is submitted by a physician who is not a member of a FHN or FHO group, the claim will reject to the physician’s error report EPA “Network Billing Not Allowed.” The Q590A fee code is not payable in addition to the G700A sole visit premium fee schedule code. For flu shots administered together with a medical assessment, the appropriate assessment code should be billed together with a G590; the Q590A fee code is not payable with an assessment. 

Eligible models

FHN and FHO

Preventive care fees and bonuses (Q100A-Q123A)

Eligible patient enrolment model physicians may receive cumulative preventive care bonuses for maintaining specified levels of preventive care to their enrolled patients. There are five preventive care categories for which an individual physician may earn an annual bonus.

The requirements for the FHG and CCM minimum roster sizes are as follows:

• Eligibility is based on a physician’s roster size on March 31 of the current bonus year (e.g., March 31, 2013, for the 2012-13 fiscal year)
• In each bonus year, a physician must have a minimum roster size of 650 enrolled patients on the last day of each fiscal year (e.g., March 31, 2013, for the 2012-13 fiscal year)
• New graduates in their first year of practice with a FHG or CCM will be required to have a minimum roster size of 450 enrolled patients. It is important to remember that the minimum roster size is calculated based on the physician’s enrolled patient roster on March 31 of each year

There are no minimum roster size requirements for FHO or FHN physicians to be eligible for this bonus.

Influenza vaccine

This bonus fee is based on the percentage of the target population who have received the influenza vaccine appropriate for that influenza season by Jan. 31 of the fiscal year for which the bonus is being claimed. The target population consists of enrolled patients who are 65 years or older as of
Dec. 31 of the fiscal year.

Pap smear

This bonus is based on the percentage of the target population who have received a Pap smear in the 42 months prior to March 31 of the fiscal year for which the bonus is being claimed. The target population consists of enrolled female patients who are between 21 and 69 years of age, inclusive, as of March 31 of the fiscal year.

Mammography

This bonus is based on the percentage of the target population who have received a mammogram in the 30 months prior to March 31 of the fiscal year for which the bonus is being claimed. The target population consists of enrolled female patients who are between 50 and 74 years of age, inclusive, as of March 31 of the fiscal year.

Childhood immunizations

This bonus is based on the percentage of the target population who have received all of the ministry-supplied immunizations as recommended by the National Advisory Committee on Immunization. The target population consists of enrolled patients who are aged 30 to 42 months of age, inclusive, as of March 31 of the fiscal year. These patients must have received all applicable immunizations by their 30th month of age.

Colorectal cancer screening

This bonus is based on the percentage of the target population who have received a Fecal Occult Blood Test in the 30 months prior to March 31 of the fiscal year for which the bonus is being claimed. The target population consists of enrolled patients who are between 50 and 74 years of age, inclusive, on March 31 of the fiscal year.

Tracking and exclusion code fees

To help physicians monitor patient status and determine service levels achieved, tracking and exclusion codes have been introduced. When submitted, these codes will identify the patient as having received the preventive care service or identify the patient as having met the criteria for being excluded from the target population for a specific preventive care service. 

Tracking and exclusion codes may be submitted using the normal billing practices used to submit fee-for-service claims and premium codes applicable to their agreement. As with other tracking codes, the fee billed should be $0, and the fee paid on the remittance advice will be $0 with explanatory code 30 – “This service is not a benefit of OHIP.”

For more, download the primary care Q-codes reference guide.

Physician registration and the OHIP billing number

To submit claims to the Ontario Health Insurance Plan for services rendered, a physician must obtain an OHIP billing number.

Before obtaining an OHIP billing number, a physician must hold a valid certificate from the College of Physicians and Surgeons of Ontario and report the practice address to the Ministry of Health. Where multiple addresses exist, the physician should identify which address is the primary practice site, where possible.

Learn more about how to register with the CPSO.

To obtain an OHIP billing number, physicians must complete the Application for OHIP Billing Number for Health Care Professionals and return it to the ministry for processing. Once the form is approved and processed, the ministry will provide the physician with an assigned billing number and the effective date.

Once a physician has a billing number, they may bill retroactively up to six months prior to receiving the billing number but no earlier than the effective date of the physician’s certificate.

Responsibilities associated with the OHIP billing number

The physician is solely responsible for all claims submitted to and paid by OHIP under that physician’s billing number, whether the physician submits their own claims or uses a “billing agent” or other third party to submit claims. Once payment has been made, if services are found to not be in compliance with the provisions of the Health Insurance Act or the regulations in the OHIP Schedule of Benefits, the physician remains solely responsible for repayment of the claim to OHIP. Learn more about the post-payment review process.

Group numbers

A group number is a ministry-issued number that allows individual physicians to have their billings associated with a group. It is not a billing number.

When a claim is submitted with a group number on the claim, the payment is usually made to the group’s bank account, if so directed (there are exceptions for some specialist group contracts where, if the contract allows, the payment is directed to the individual physician). However, the individual physician (whose billing number is on the claim) is responsible for the claim. Examples where a group number may be used include primary health-care models (e.g., Family Health Organization, Family Health Group), alternate payment programs (e.g., emergency department alternate funding arrangement, academic health science centres) or other hospital or clinical groups where staff may submit billing.

Download the general principles of OHIP billing guide.

Patients with expired and expiring health cards

Since March 2020, coverage has been expanded to include:

• Most expired OHIP cards remain valid; health card validation response codes 50-55 (inclusive) indicate that the card is valid to access insured services
• Only the most recent version code will be accepted for expired health cards
• Red and white health cards will be accepted unless invalid

Patients without health insurance (uninsured)

Since March 2020, coverage has been expanded to include:

• All medically necessary hospital services for patients who are not covered by OHIP, another provincial/territorial or federal health-care plan or private insurance are funded. Hospitals were provided a spreadsheet to submit billings to OHIP. After receiving remuneration, hospitals are responsible for distributing payments to physicians
• Limited medically necessary physician services performed in-person or by telephone or video in the community are also funded for patients who are not covered by OHIP or another provincial/territorial or federal health-care plan. These fee codes are to be claimed through the OHIP claims payment system:
  • Minor assessments (K087)
  • Intermediate assessments (K088)
  • Psychotherapy, psychiatric or primary mental-health care, counselling or interview (K088 or K089 depending on the duration)
• Services performed in the community that are not captured by these codes (for example, procedures) can be billed to patients until they can provide a valid health card indicating they were insured on the date the service was provided. Providers should then reimburse the patient

Patients with invalid health cards (lost, stolen, damaged or voided)

In all cases, providers should follow existing health card validation services to determine health card validity.

Patients should be provided the ServiceOntario INFOline (1-800-268-1154) or be advised to visit their local ServiceOntario centre.

The provider can contact the ServiceOntario help desk (1-866-532-3161) to obtain accelerated release of health card numbers and version codes.

If by using the ministry’s health card validation mechanisms it is determined that a patient’s health card is invalid:

• Services performed in the hospital may be claimed to the ministry on the hospital’s spreadsheet of claims for services provided to uninsured patients
• Services provided to uninsured patients in the community may not be claimed to the ministry and providers should use existing processes for expired or invalid health cards in these scenarios (for example, bill the patient directly for the health care service(s) provided)
• If the patient is billed directly and subsequently provides proof they were insured on the date of service (for example, through providing updated health card information), then the provider would be required to reimburse the patient and bill OHIP accordingly

Patients with other provincial, federal or private health insurance

Billing submission to insurance providers should continue as before the pandemic.

Download the physician remuneration for expired health cards guide.

Definition of a special visit premium

A special visit is one that requires the physician to assess a patient:

• In response to a request initiated by the patient or a person caring for the patient (non-elective visit)
• On a physician-initiated visit to a patient’s home (elective visit), provided the patient’s home is not a long-term care facility, including a nursing home or home for the aged

A special visit premium is payable in respect of a special visit rendered to an insured person, subject to the conditions and limitations set out in the Schedule. All special visit premiums are subject to the maximums, limitations and conditions.

Sacrifice of office hours refers to circumstances when the physician makes a previously unscheduled non-elective visit to the patient at a time when they had previously booked office visits that had to be delayed or cancelled because of the special visit.

Components of a special visit

Special visit premiums are separated into two components: a travel premium and a person seen premium (i.e., first or additional person seen). The location, circumstances, time and specialty will determine the applicable special visit premium(s) eligible for payment in addition to the service provided.

Travel premium

The travel premium is eligible for payment for travel from one location to another (the destination). Only one travel premium is eligible for payment for each separate trip to a destination, regardless of the number of patients seen in association with each trip.

The travel premium is not eligible for payment when a physician is required to travel from one location to another within the same long-term care facility, hospital complex or buildings situated on the same health-care campus.

First person seen premium

The first person seen premium is eligible for payment for the first person seen at the destination if rendered during the eligible times, or if rendering it required the sacrifice of office hours.

Additional person(s) seen premium

The additional person(s) seen premium is for services rendered at the destination to additional patients seen in emergency departments, outpatient departments, long-term care institutions or hospital in-patients, provided that each additional patient seen meets the special visit criteria and the service is commenced during the eligible times. This would include any new patients the physician is requested to attend to on a non-elective basis at the destination.

Location

The premiums apply to special visits to:

• An emergency department (by a non-emergency department physician)
• A hospital outpatient department 
• A hospital in-patient
• A long-term care institution
• An emergency department by an emergency department physician
• A special visit to a patient’s home (other than a long-term care institution)
• A palliative care home visit
• A physician’s office
• Other (non-professional setting not listed)
• A geriatric home visit

Type of service rendered

The Schedule also lists special visit premiums specific to special visits required for:

• Anesthesia services
• Surgical assistant services
• Non-elective diagnostic services
• Obstetrical delivery with sacrifice of office hours

Read more in the special visit premiums guide.