Request a Blog: A36 & 36 OHIP Rejection Codes

OHIP rejection codesAs we’ve mentioned before, 3 character OHIP rejection codes come up on error reports, while 2 character codes are found on the Remittance Advice payment report that comes from the Ministry of Health monthly. Rejection codes often have counterparts for both error reports and RA’s, so we’ll look at A36 as well as code 36, as requested by one of our readers.

A36 Error Code – Claimed by another physician/ practitioner

A number of codes are only payable to one physician, or one specialist per day. This condition can be clearly indicated in the Schedule of Benefits, or can be “understood” according to the definition of that service code. If you see A36 on an error report, another physician submitted the same code for the same patient on the same date of service… and that MD submitted it first. In most circumstances, the MOH will not get involved in competition over codes. However, there are some grounds for petitioning the claims assessor to reconsider your claim. This would be done by resubmitting the claim with the manual review indicator, and adding an explanation and notes if applicable.

 

Error reports versus RA rejections
Codes that come back on error reports are no longer on file at the Ministry of Health. What this means in practice is that those codes will not be processed for payment unless you resubmit them with the appropriate corrections or explanations. The same is not true for rejections on the RA. RA claims were processed for payment and approved at some amount ($0.00, a portion of the amount, or the full amount). The RA inquiry form must be filled out and sent to the claims assessor at the correct district office in order challenge payment decisions.

 

36 Explanatory Code – Service rendered by another physician/ practitioner

The definition of 36 is the same as for A36 above: another physician was paid for this code. The difference is that 36 will come up on the Remittance Advice payment report, and represents a payment decision for a claim. 36 can come up for assessments paid to another physician, certain premiums limited to one doctor (such as the E083 MRP Premium), and procedures that are only allowed for one MD per day.

An Example:

Service Codes Error Codes RA Explanatory Codes Reason for Rejection
A135 A36 36 Paid to other MD
K996 ADF DF Code not allowed alone

In this case, the internal medicine consultation was billed in the emergency department with a special visit premium showing “first patient seen after midnight”. In any speciality, the MOH will reject the second consult by a specialist on the same date, since it is rare for two to be necessary. Thus A135 is rejected A36/36, and the special visit can’t be billed without an assessment, so it is rejected ADF/DF.

What to do?

Here we could resubmit the claim or send an RA inquiry with notes showing that the doctor with the rejection was the first to assess the patient on that service date. That is grounds for reconsideration – but not a guarantee of payment. Alternately, if the physician with the rejection feels that their consultation was medically necessary, they could submit notes to that effect in a manual review or RA inquiry, depending on the rejection circumstances.

We hope this helps, and invite all our readers to submit their questions on codes.

More on Error Codes                     More on Remittance Advice

 

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