MEDCOM

Wondering what Remittance Advice Codes mean?

Use the following as an easy reference when reconciling.

30

Service is not a benefit of OHIP (Ontario Health Insurance Plan)

31

Not a valid network service

32

OHIP records show service(s) on this day claimed previously

33

Approved

35

OHIP records show this service rendered has been claimed previously (used on Pay Practitioner duplicate claims)

36

OHIP records show service has been rendered by another Practitioner, Group, Lab

37

Effective April 1, 1993 the listed benefit for this code is 0 Laboratory Medicine Services (LMS) units

40

Service or related service allowed only once for same patient

41

Fee Schedule Code (FSC) Billed - No Evidence in Supporting Documentation Provided

42

FSC Billed Included in Other Procedure

45

Specialty code restriction on Fee Schedule Code

46

Paid Per 2nd Review by Medical Advisor (MA)

47

Not Paid Per 2nd Review by Medical Advisor (MA)

48

Paid as submitted - clinical records may be requested for verification purposes

49

Paid according to the average fee for this service. Independent consideration will be given if clinical records/operative reports presented.

50

Paid in accordance with the Schedule of Benefits

51

Fee Schedule Code changed in accordance with Schedule of Benefits

52

Fee-for-service assessed by medical consultant

53

Fee allowed according to appropriate item in a previous Schedule of Benefits

54

Interim payment - claim under review

55

Deduction is an adjustment on an earlier account

56

Claim under review

57

This payment is an adjustment on an earlier account

58

Claimed by another physician within group

59

Practitioner's notification - WCB claims

60

Not a benefit of the Reciprocal Medical Billing Agreement

62

Claim assessed by Assessment Officer

65

Service included in approved hospital payment

66

Reduced per Alternative Payment Program (APP) Funding Contract

69

Elective Services Paid At 75% Of OHIP Schedule of Rates

70

OHIP records show corresponding procedure(s) on this day claimed previously by another physician

80

Technical fee adjustment for hospitals

AP

This payment is in accordance with legislation. If you disagree with the payment, you may appeal to the General Manager

AH

Not allowed in addition to health exam

B1

Service Not Eligible for Payment When Delivered by Telephone

B2

Paid in accordance with the OHIP Schedule of Benefits for Telephone Virtual Care Services

B3

Patient-Physician Relationship Requirements Not Met

B4

Virtual Service not allowed in addition to In-Person Equivalent Service

B5

In-Person Service Not Allowed in Addition to Virtual Equivalent Service

B6

Limited Virtual Care Service Already Paid

B7

Comprehensive Virtual Care Service Already Paid

B8

Service Not Eligible for Payment Virtually

C1

Allowed as repeat/limited consultation/midwife-requested emergency assessment

C2

Allowed at re-assessment fee

C3

Allowed at minor assessment fee

C4

Consultation not allowed with this service-paid as assessment

C5

Allowed as multiple systems assessment

C6

Allowed as Type 2 admission assessment

C7

An admission assessment (C003A) or general re-assessment (C004A) may not be claimed by any physician within 30 days following a pre-dental/pre-operative assessment

C8

Payment reduced to geriatric consultation fee-maximum number of comprehensive geriatric consultations has been reached

C9

Allowed as in-patient interim admission orders-initial assessment already claimed by other physician

D1

Allowed as repeat procedure-initial procedure previously claimed

D2

Additional procedures allowed at 50%

D3

Not allowed in addition to visit fee

D4

Procedure allowed at 50% with visit

D5

Procedure already allowed-visit fee adjusted

D6

Limit of payment for this procedure reached

D7

Not allowed in addition to other procedure

D8

Allowed with specific procedures only

D9

Not allowed to a hospital department

DA

Maximum for this procedure reached - paid as repeat/chronic procedure

DB

Other dialysis procedure already paid

DC

Procedure paid previously not allowed in addition to this procedure- fee adjusted to pay the difference

DD

Not allowed as diagnostic code is unrelated to original eye exam

DE

Lab tests already paid-visit fee adjusted

DF

Corresponding fee code was not billed or paid at zero

DG

Diagnostic/Miscellaneous services for hospital patients are not payable on a fee-for-service basis in the Hospital Global budget.

DH

Ventilatory support allowed with Haemodialysis

DL

Allowed as laboratory tests in private office

DM

Paid/disallowed in accordance with MOH policy regarding an Emergency Department Equivalent

DN

Allowed as pudenal block in addition to procedure-as per stated OHIP policy

DP

Procedure paid previously allowed at 50% in addition to this procedure-fee adjusted to pay the difference

DR

Self-Referred Diagnostic Services Payable at 50%

DS

Not allowed-mutually exclusive code billed

DT

In-patient technical fee not allowed

DV

Service is included in Monthly Management Fee for Long-Term Care (LTC) patients

DW

Procedure paid previously not allowed in addition to monthly management. For long-term care patients-fee adjusted to pay the difference.

DX

Diagnostic code not eligible with Fee Schedule Code

E1

Service date prior to start of eligibility

E2

Incorrect version code for service date

E3

Version Code not on File for HN (Health Number)

E4

Service date after the eligibility termination date

E5

Service date not within an eligible period

E6

Service Date after Eligibility End Date - Eligibility Terminated as MOH Records Indicate Patient Deceased

E9

Service Date after Eligibility End Date - Eligibility Terminated Due to no Response to Notice to Register

EA

Service date is not within an eligible period - Services provided on or after the 20th of this month will not be paid unless eligibility status changes

EB

Coding added/changed in accordance with Schedule of Benefits

EE

Assessment Allowed at Full Fee for Patient Proceeding to Hospital

EF

Incorrect version code-services provided on or after the 20th of this month will not be paid unless the current version code is provided

EN

Network billing not allowed

EP

This payment is an adjustment of an earlier account due to provider registration update

EV

Check health card for current version code

F1

Additional fractures/dislocations allowed at 85%

F2

Allowed in accordance with transferred care

F3

Previous attempted reductions (open or closed) allowed at 85%

F5

Two weeks aftercare included in fracture fee

F6

Allowed as Minor/Partial Assessment

FF

Additional payment for the claim shown

G1

Other critical/comprehensive care already paid

GF

Coverage lapsed-bill patient for future claims

H1

Admission assessment or Emergency department assessment already paid

H2

Allowed as subsequent visit - initial visit previously claimed

H3

Maximum fee allowed per week after 5th week

H4

Maximum fee allowed per week after 6th week to pediatricians

H5

Maximum fee allowed per month after the 13th week

H6

Allowed as supportive or concurrent care

H7

Allowed as chronic care

H8

Hospital number and/or admission date required for in-hospital service

H9

Concurrent care already claimed by another doctor

HA

Admission assessment claimed by another physician-hospital visit fee applied

HB

Subsequent Visit Already Paid Same Day

HF

Concurrent or supportive care already claimed in period

HM

Invalid master number used on date of service

I2

Service is globally funded

I3

Fee Schedule Code is not on the IHF (Independent Health Facility) licence profile for the date specified

I4

Records show service has been rendered by another Practitioner, Group or IHF

I5

Service is globally funded and Fee Schedule Code is not on IHF licence profile

I6

Premium not applicable

I7

Claim date does not match patient enrolment date

I8

Confirmation not received

I9

Payment not applicable/expired

J1

Service Date is Before the Effective Date of OHIP Coverage

J2

Service Date is After the Termination of Coverage Date

J3

Approved for stale dated processing

J5

Coverage Applied For; Premiums Not Yet Paid

J7

Claim submitted six months after service date

J8

Coverage Not In Effect; Services Provided On Or After The 20th Of This Month Will Not Be Paid Unless Subscriber Takes Corrective Action

J9

Coverage Reinstated. Submit Claims Routinely

L1

This service paid to another laboratory

L2

Not allowed to medical Laboratory Director

L3

Not allowed in addition to other laboratory procedure(s)

L4

Not allowed to attending physicians

L5

Not allowed in addition to other procedure paid to another laboratory

L6

Procedure paid previously to another laboratory, not allowed in addition this procedure-fee adjusted to pay the difference

L7

Not allowed-referred specimen

L8

Not to be claimed with prenatal/fetal assessment

L9

Laboratory services for hospital in-patients or out-patients are not payable on a fee-for-service basis-included in the hospital global budget

LA

Lab service is funded by special Lab Agreement

LS

Paid in accordance to special Lab Agreement

M1

Maximum fee allowed or maximum number of service has been reached same/any provider

M2

Maximum allowance for radiographic examination(s) by one or more practitioners

M3

Maximum fee allowed for prenatal care

M4

Maximum fee allowed for these services by one or more practitioners has been reached

M5

Monthly maximum has been reached

M6

Maximum fee allowed for special visit premium-additional patient seen

MA

Maximum number of sessions has been reached

MC

Maximum number of case conferences has been reached in a 12 month period

MD

Daily maximum has been exceeded

ME

Maximum number of e-assessments paid

MM

Claim does not meet requirements of the Physician Schedule of Benefits

MN

Maximum number of occipital nerve block sessions has been reached

MO

Maximum number of Optical Coherence Tomography (OCT) services has been reached

MR

Minimum service requirements have not been met

MS

Maximum allowed for sleep studies in a specific period by one or more physicians has been reached

MX

Maximum of 2 arthroscopy "R" codes with E595 has been reached

MU

Maximum Units Exceeded

MW

Maximum Number of Weeks has elapsed since payment of initial service

MY

Yearly maximum has been exceeded

O1

Fee for obstetric care apportioned

O2

Previous prenatal care already claimed

O3

Previous prenatal care already claimed by another doctor

O4

Office visits relating to pregnancy and claimed prior to delivery included in obstetric fee

O5

Not allowed in addition to delivery

O6

Medical induction/stimulation of labour allowed once per pregnancy

O7

Allowed as subsequent prenatal visit-initial prenatal visit already claimed

O8

Allowed once per pregnancy

O9

Not allowed in addition to post-natal care

P2

Maximum fee allowed for low birth weight care

P3

Maximum fee allowed for newborn care

P4

Fee for newborn care/low birth weight care is not billable with neonatal intensive care

P5

Over-age for paediatric rates of payment

P6

Over-age for well-baby care

P8

Health Care Connect greater than 3 months

P9

Complex New patient

PM

Minimum roster size not met

Q7

No fee allowed for treatment of immediate family

Q8

Lab not licensed to perform this test on date of service

R1

Only one health exam allowed in a twelve-month period

R2

10 Well Baby Visits Allowed Up To Two Years Of Age

R3

One Well Child Exam (Age 2-5 Years) Allowed Within A12 Month Period

RD

Duplicate, paid in Reciprocal Medical Billing System (RMBS)

S1

Bilateral surgery, one stage, allowed at 85% higher than unilateral

S2

Bilateral surgery, two stage, allowed at 85% higher than unilateral

S3

Second surgical procedure allowed at 85%

S4

Procedure fee reduced when paid with related surgery or anaesthetic

S5

Not allowed in addition to major surgical fee

S6

Allowed as subsequent procedure-initial procedure previously claimed

S7

Normal pre-operative and post-operative care included in surgical fee

S9

Initial procedure not found

SA

Surgical procedure allowed at consultation fee

SB

Normal pre-operative visit included in surgical fee-visit fee previously paid-surgical fee adjusted

SC

Not allowed, major pre-operative visit already claimed

SD

Not allowed, Team/Assist Fee already claimed

SE

Major pre-operative visit previously paid and admission assessment previously paid-surgery fee reduced by the admission assessment

SF

Most Responsible Physician (MRP) visit not allowed during post- operative period-surgical fee adjusted

SV

MRP visit not allowed during post-operative period-fee reduced to subsequent visit fee

SW

Intensive Care Unit per diem code paid to another physician-MRP subsequent visit reduced to subsequent visit

SX

ICU Per Diem code Paid To Another Physician, MRP Premium Not Allowed

T1

Fee allowed according to surgery claim

V1

Allowed as repeat assessment-initial assessment previously claimed

V2

Allowed as extra patient seen in the home

V3

Not allowed in addition to procedural fee

V4

Date of service was not a Saturday, Sunday or statutory holiday

V5

Only 1 major oculo-visual examination allowed in a 12-month period for under 19 or over 65 with medical condition; 1 in 18-month period for over 65 without medical condition

V6

Allowed as minor assessment-initial assessment already claimed

V7

Allowed at medical/specific re-assessment fee

V8

This service paid at lower fee as per stated OHIP policy

V9

Only one initial office visit allowed within a twelve-month period

VA

Procedure fee reduced-consultation/visit fees not allowed in addition

VB

Additional Oculo-Visual Assessment (OVA) is allowed once within the second year for patients aged 20-64, following a periodic OVA

VC

Procedure Paid Previously Not Allowed In Addition To Visit Fee. Fee Adjusted To Pay The Difference

VG

Only one geriatric general assessment premium per patient per 12- month period

VM

Oculo-visual minor assessment is only allowed within eligibility period after a major oculo-visual examination

VN

Allowed as a major oculo-visual examination for seniors with medical conditions

VP

Allowed with special visit only

VR

Visit reduced premium not applicable

VS

Date of service was a Saturday, Sunday or statutory holiday

VX

Complexity premium not applicable to visit fee

W3

Warning: - Service date is older than 3 months

W4

Warning:-service location indicator code missing

X2

Gastrointestinal (G.I.) tract includes cine and video tape

X3

Gastrointestinal (G.I.) tract includes survey film of abdomen

X4

Only one Bone Mineral Density (BMD) allowed within a 36 month period for a low risk patient

X5

Only one Bone Mineral Density (BMD) allowed within a 12 month period for a high risk patient

X6

Only one Bone Mineral Density (BMD) allowed within a 60 month period for a low risk patient