MEDCOM

Rejection Conditions

A1A

Outside Service Period

A2A

Outside of Age Limit - Patient is underage or overage for this service code

A2B

Wrong Sex for Service - This service is not normally performed for this sex. Please check your records.

A3E

No such service code for date of service

A3F

No fee exists for this service code on this date of service

A3G

Fee Billed Low

A3H

Maximum Number Services per the Fee Schedule Master (FSM)

A3I

X-Ray Code - Maximum Number Services per the FSM

A3L

Other New Patient Fee Already Paid

A34

Multiple duplicate claims

A36

Claimed by Other Practioner

A4D

Invalid specialty for this service code

AC1

Maximum reached-resubmit alternate Fee Schedule Code (FSC)

AC4

Unaccepted Referral Number.

• Not 6 numerics
• Equal to the Practitioner billing number
• Referring number is 722900-744292 (Nurse Practitioner (NP)) and FSC is not eligible for NP referral.
• Referring number is 700000-722899 (Midwife (MW)) and FSC is not eligible for MW referral.

AD3

Not allowed with visit

AD5

Procedure allowed previously

AD8

Not allowed alone

AD9

Premium not allowed alone

ADF

Corresponding Procedure Invalid, Omitted or Paid at zero

ADH

Cannot be billed together

AH8

Invalid Admission Date and/or Hospital number.

AHF

Concurrent or Supportive Care Same Period

AM1

Service Limit Exceeded

AMR

Minimum service requirements have not been met

AMS

Multiple Procedures

AO2

Previous Obstetrical Service

AO3

Most Responsible Physician (MRP) Visit Already Paid

ARF

Missing Physician Referring Number

ARP

Referring Physician Number Required

ASP

Not Allowed with Surgical Procedure

AT1

Only One Modality Allowed

AT2

Must Include Video Modality

AT3

No Patient-Physician Relationship

AT4

Modality Not Allowed

EF1

IHF number not approved for billing on the date specified

EF2

IHF not licensed or grandfathered to bill FSC on the date specified

EF3

Insured services are excluded from IHF billings

EF4

Provider is not approved to bill IHF fee on date specified

EF5

IHF practitioner 991000 is not allowed to bill insured services

EF7

Referring physician number is required for the IHF fee billed

EF8

'I' service codes are exclusive to IHFs

EF9

Mobile site number required

CNA

Counselling Not Allowed

EG1

Group not Eligible

EH1

Service Date before Eligibility Effective Date

EH2

Mismatched Version Code

EH4

Service Date after Eligibility End Date

EH5

Service Date Not in Eligibility Period

EH6

Eligibility Terminated-Deceased

EH9

Health Number (HN) Not Activated

ENP

Invalid FSC for Nurse Practitioner (NP)

EPA

Network billing not approved

EPC

Patient not rostered/rostered to another Network

EPF

Enrolment Date Mismatch

EPP

Incorrect Code for Eligibility (Ontario Works/Ontario Disability Support Program)

EPS

Patient Not Eligible for Program

EP1

Enrolment Transaction Not Allowed

EP2

Not for Enrolment/ReEnrolment

EP3

Incorrect Service Date – Check Date of Enrolment

EP4

Enrolment Restriction Applied

EP5

Incorrect FSC for Group Type

EP6

HN Not Activated

EP7

Code must be billed alone

EQ1

Clinic/Doctor Not on File - Practitioner not registered with OHIP

EQ2

Specialty mismatch – Specialty Code is inactive or not registered on date of service

EQ3

Claim submitted as Pay Patient - Health care provider is registered as OPTED-IN for date of service

EQ4

Claim submitted as Pay Provider - Health care provider is registered as OPTED-OUT for date of service

EQ5

Lab inactive on Service date

EQ6

Incorrect Referral Number - Referring/requisitioning health care provider number is not registered with the Ministry of Health

EQ9

Lab Number not on File

EQB

Invalid practitioner number

• Solo practitioner inactive on service date
• Practitioner number is Midwife (700000-722899) referral only
• Claims submitted by Chiropractors using their Claim Submission Number (CSN)
• Physician Registered as group billing only

EQC

Group not registered

EQD

Group inactive on service date

EQE

Affiliated Practitioner not in Group - Health care provider is not registered with the Ministry of Health as an affiliate of this group on date of service

EQF

Affiliated Practitioner inactive - Health care provider is not actively registered with the Ministry of Health as an affiliate of this group on date of service

EQG

Referring laboratory is not registered with the Ministry of Health

EQI

Contract characteristics error

EQJ

Practitioner Not Eligible On Service Date - New Graduate bills New Patient fee (Q013) or Physician (not a new graduate) bills new Graduate-New Patient fee (Q033).

EQK

Master Number (MNI) Does not Meet Criteria - A100 billed with a specialty code other than 00.

EQL

Physician Not Eligible to Claim FSC - A100 billed with a speciality code other than 00 or billed by provider with any Emergency Department Alternate Funding arrangement (EDAFA) group number.

EQM

Not Registered for Use

EQN

Registration Usage Error on Service Date

EQP

Enrolment Type Not Eligible

EQS

Practitioner Criteria Not Met

ERF

Referring physician number is currently ineligible for referrals

ESD

APP group affiliation on service date - Hospital Emergency Department is part of an alternative funding agreement

ESF

Not eligible to bill

ESH

Not Eligible For Blank HN

ESN

Invalid Blank HN Claim - No HN required for FSC

ET1

Not Registered for Telemedicine

ET4

Telemedicine Premium/Tracking Code Missing

ET5

Telemedicine SLI Missing/Invalid - The telemedicine billing is submitted with a telemedicine tracking code but the SLI code is not 'OTN' or is not present.

HCC

Health Care Connect (HCC) Error:

• Not on Health Care Connect (HCC) database-Not Eligible
• On HCC database but not Complex-Vulnerable
• On HCC database but not in 'referred to' status

HCE

Patient enrolled to billing physician but later than 3 months from the "referred to" date on HCC database-Enrolment after 3 Months

PAA

No Initial Fee Previously Paid - To ensure the smoking cessation initial discussion fee (E079) has been paid within 365 days prior to the smoking cessation counseling fee (Q042) or the smoking cessation follow up fee (K039)

PA1

Invalid PA Service - Physician Assistant (PA) Pilot claim submissions may contain one or more PA Tracking FSC's but other OHIP insured service FSCs are not allowed on the same claim.

PA2

Invalid PA Claim - Physician Assistant Pilot (PA) claim submissions with the PA as the submitting physician must identify the solo billing number of the supervising physician in the "Refer Physician" field.

PA3

Not registered for PA - The physician and/or referring physician fields on the PA Pilot claim submission contain billing numbers which are not affiliated to the PA Pilot group number.

PA4

PA Registration on Service Date Error

PA5

PA Affiliation Error

PA6

PA Affiliation on Service Date Error

R01

Missing Health Service Number (HSN)

R02

Invalid HSN

R03

Invalid/Missing Province Code

R04

Service Excluded from RMBS

R05

Provincial code invalid for RMBS: Province code of 'ON' (Ontario) or ‘PQ’ (Quebec) and not an Outaouais claim

R06

Invalid Provider for RMBS

R07

Invalid Payment Type for RMBS

R08

Invalid Referral Number

R09

Claim Header 2 Missing-RMB

TM1

Duplicate Telemedicine Claim, Same patient

TM2

Service not Billable for Missed/ Cancelled/Abandoned Appointment

TM3

Service not payable underTelemedicine Program

TM4

Non Telemedicine Claim paid for same patient

TM5

Telemedicine Claim Paid for same patient

TM6

Registration not in effect on Service Date

TM7

Dental Service not eligible for Telemedicine

TM8

Not eligible for Store Forward

V02

Invalid Region Code

V05

Error-Claim Number is less than Service Date

V06

Incorrect Clinic Code

V07

Invalid Practitioner Number

V08

Invalid Specialty Code:

• Not a valid specialty code
• Specialty code is 27 and provider number is not 599993
• Specialty code is 90 and provider number is not 991000
• Specialty code is 49, 50, 51, 52, 53, 54, 55, 70 and 71 and the health care provider number does not begin with 4
• Specialty code is 56 and health care provider number does not begin with 80 or 81
• Specialty code is 80 or 81 and health care provider number does not begin with 82

V09

Invalid Referral Number

V10

Patient's last name is missing/not alphabetic (A-Z): First field position is blank

V12

Patient's first name is missing/not alphabetic (A-Z): First field position is blank

V13

Patient's date of birth is missing/invalid format

• Month not in the range of 01-12
• Not 8 numerics
• Day is outside acceptable range for month

V14

Patient sex must be '1' (male) or '2' (female)

V16

Unacceptable Diagnostic Code: Not numeric

V17

Payee must be 'P' (Provider) or 'S' (Patient)

V18

Invalid Amission/First Visit date

V19

Invalid Chiropractor Diagnostic Code

V20

Unacceptable Age for Diagnostic code

• Service code is A007, patient is over 2 years old and diagnostic code is '916' or
• Service code is A003 and the patient is under 16 years old and the diagnostic code is '917'

V21

Diagnostic Code Required

V22

Invalid Diagnostic Code

V23

Check Number Of Services

V28

Invalid Hospital Number

V29

Invalid In-Out-Patient Indicator

V30

FSC/Diagnostic Code Combination Not A Benefit (NAB)

V31

Error in Claim Header - Missing any of the following: group number, health care provider number, specialty code

V34

Invalid Service Code: Service Code and Health Care provider type mismatch

V35

Invalid Out-of-Province/Out-of-Country Service

V36

Check input criteria required for sessional billing

V39

Number of items exceeds the maximum (99)

V40

Invalid Fee Schedule Code

• Service code is missing
• Service code is not in the format ANNNA where:
  • A is alphabetic (A-Z)
  • NNN is numeric (001-999)
  • A is alphabetic (A-C)

V41

Invalid Fee Billed

• Fee submitted is missing/not 6 numerics
• Fee submitted is not in the range '000000'-'500000' ($$$$cc)

V42

Invalid Number of Services\

• Number of services is missing/not 2 numerics
• Number of services is not in the range '01-99'

V47

Fee not Divisible - Fee submitted is not evenly divisible (to the cent) by the number of services

V50

Service Date Pre Initial Visit - Physiotherapy

V51

Invalid location code - must be blank or four numerics. If present, must be valid based on MOHLTC Residency Code Manual

V53

Invalid FSC-Magnetic Tape/Disk

V62

Invalid service location indicator - hospital diagnostic service billing from a participating hospital physician/group is not of the five valid SLI codes (HDS, HED, HIP, HOP or HRP)

V63

Referring Laboratory Number must start with 5 (5###)

V64

Missing service location indicator

V65

Missing master number - SLI code HDS, HED, HIP, HOP or HRP is included with a diagnostic service billing but a master number was not included

V66

Missing admission date - SLI code HIP is included with a diagnostic service billing but an admission date was not included

V67

Missing master number and admission date - assigned when a SLI code HIP is included with a diagnostic service billing but a master number and admission date were both not included

V68

Incorrect service location indicator - assigned when a diagnostic service is billed with a master number and admission date but the SLI code is not HIP

V69

Service Date Invalid for SLI

V70

Date of service is greater than the file/batch creation date

V71

Invalid Dental Master Number

V73

OTN SLI No Longer Active

V98

Wrong Preventive Care Date of Service

VHA

OHIP number not registered with ministry for health number

VHB

No HN Required for FSC: A non-encounter service claim submitted with a Health Number

VH0

Header 2 and HN Present: Claim Header-2 present on MRI claim submitted with Health Number in Claim Header-1

VH1

Health Number is missing/invalid

VH2

Health Number is MissingHealth Number is not present (Payment program is HCP or WCB)

VH3

Invalid Payment Program: d>The payment program is missing or is not equal to HCP, RMB, WCB

VH4

Invalid Version Code

VH5

OHIP Number Required for Service Date

VH6

Mixed Service Dates

VH7

Health number and OHIP number on same claim

VH8

Date of birth does not match the Health Number submitted

VH9

Health Number is not registered with ministry

VJ5

Invalid Service Date

• Date of Service is missing/not 8 numerics
• Month is not in the range 01-12
• Day is outside acceptable range for month
• Date of Service is greater than Ministry of Health system run date

VJ7

Stale-dated Claim

VJ8

Stale-dated Claim Encounter

VHC

SLI required for technical fee

VS1

Invalid SEAMO Provider Code

VS2

Invalid Venue Type

VS3

Invalid Clinic Number

VS4

Invalid Healthcare Item

VS5

Invalid In-Patient/Out-Patient Indicator

VS6

Invalid HC Item Code Format

VTC

Virtual Tech Code required

VT1

Only 1 VTC allowed

VW1

Invalid WCB Service