FAQ

Remittance Advice Explanatory Codes

Wondering what Remittance Advice Codes mean?

Use the following as an easy reference when reconciling.

Explanatory Code - Description(s) - Numeric Codes

  • 30 This service is not a benefit of OHIP
  • 31 Not a valid network service
  • 32 OHIP records show service(s) on this day claimed previously
  • 35 OHIP records show this service rendered has been claimed previously (used on Pay Practitioner duplicate claims)
  • 36 OHIP records show this service has been rendered by another Practitioner, Group, Lap
  • 37 Effective April 1st, 1993 the listed benefit for this code is 0 LMS units
  • 40 Service or related service allowed only once for same patient
  • 45 Specialty code restriction on FSC
  • 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 are 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
  • 66 Reduced per APP Funding Contract
  • 70 OHIP records show corresponding procedure(s) on this day claimed previously by another physician
  • 80 Technical fee adjustment for hospitals

Explanatory Code - Description(s) - "C" and "D" Codes

  • 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 test 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
  • DS Not allowed - mutually exclusive code billed
  • DT In-patient technical fee not allowed
  • DV Service is included in Monthly Management Fee for LTC patients
  • DX Diagnostic code not eligible with FSC

Explanatory Code - Description(s) -"E", "F" and "G" Codes

  • E1 Service date is prior to start of eligibility
  • E2 Incorrect version code for service date
  • E4 Service date after the eligibility termination date
  • E5 Service date not within an eligible period
  • 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
  • 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
  • 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

Explanatory Code - Description(s) -"H", "I" and "J" Codes

  • H1 Admission assessment or ER 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 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
  • HF Concurrent or supportive care already claimed in period
  • HM Invalid master number used on date of service
  • I2 Service is globally funded
  • I3 FSC is not on the IHF 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 FSC 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
  • J3 Approved for stale dated processing
  • J7 Claim submitted six months after service date

Explanatory Code - Description(s) - "L", "M" Codes

  • 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 services 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
  • MN Maximum number of occipital nerve block sessions 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
  • MY Yearly maximum has been exeeded

Explanatory Code - Description(s) - "O", "P", "Q" and "R" Codes

  • 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
  • P3 Maximum fee allowed for newborn care
  • P4 Fee for newborn/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 HCC GT 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
  • RD Duplicate, paid in RMBS

Explanatory Code - Description(s) - "S" and "T" Codes

  • 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
  • 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 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
  • T1 Fee allowed according to surgery claim

Explanatory Code - Description(s) - "V", "W" and "X" Codes

  • V1 Allowed as repeat assessment - initial assessment previously claimed
  • V2 Allowed as extra patient seen in home
  • V3 Not allowed in addition to procedural fee
  • V4 Date of service was not a Saturday, Sunday or statutory holiday
  • V5 Only one OVA allowed within a 12-month period for age 19 and under or 65 and over - and one within 24 months for age 20-64
  • 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 twelve-month period
  • VA Procedure fee reduced - consultation/visit fees not allowed in addition
  • VB Additional OVA allowed once within the second year for patients aged 20-64 following a periodic OVA
  • VG Only one geriatric general assessment premium per patient per 12-month period
  • VM Oculo-visual minor assessment is allowed within 12 consecutive months following a major eye exam
  • VP Allowed with special visit only
  • VS Date of service as a Saturday, Sunday or statutory holiday
  • VX Compexity premium not applicable to visit fee
  • W4 Warning: - service location indicator code missing
  • X2 G.I. tract includes cine and video tape
  • X3 G.I. tract includes survey film of abdomen
  • X4 Only one BMD allowed within a 36 month period for a low risk patient
  • X5 Only one BMD allowed within a 12 month period for a high risk patient
  • X6 Only one BMD allowed within a 60 month period for a low risk patient