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The information contained in the OHIP Schedule of Benefits requires knowledgeable interpretation and is intended primarily for members of the professional health care community. The Schedules set out the fees and requirements for payment for insured services under OHIP.
Nov 17, 2022 · Between 2016–2017 and 2020–2021, average payments increased between 3% and 12% in Atlantic Canada, and by 16% in Yukon. Quebec and Ontario also saw increases, albeit slightly smaller at 3% and 2%, respectively.
- Introduction
- Common elements
- Constituent elements
- Independent operative procedures (IOP)
- Payment Rule
- Specific elements
- 1. Preambles
- 2. Consultations and visits
- 3. Specialty Sections
- 4. Surgical Procedures
- Out-patient Internal Medicine Consultation
- How the Schedule works
- Specific
- Example: Understanding the differences between different types of assessment
Glossary of selected terms used in the module Legal and regulatory framework Uninsured services Medical records Organization of the Schedule Fee schedule codes and naming conventions How the Schedule works More information Help us improve our learning modules Objectives Upon completion of this module, the learner should be able to: Describe the pur...
The components that are included in the payment for all insured physician services. The common elements are listed in the General Preamble.
Payment for an insured service includes compensation for performing any applicable common and specific elements of the service, as well as the skill, time and responsibility involved in performing the service. All elements taken together are referred to as the constituent elements of a service.
Payment for surgical procedural codes without a Z prefix include pre/post operative care. (although first and second-day visits and day of discharge visits may be separately claimed by the Most Responsible Physician (MRP)), whereas surgical procedural codes with a Z prefix are independent operative procedures denoted throughout the Schedule as an I...
A payment rule specifies a condition that must be met for a listed service to be insured. These are variously titled in the Schedule including: payment rule, medical records requirement, note, etc.
Components that only apply to specific groups of services. The General Preamble lists specific elements that apply to some groups of services (for example assessments). However, specific elements for other groups of services may be listed in the additional preambles throughout the Schedule (for example the Surgical Preamble). Tip: Additional defini...
The General Preamble is an essential reference for billing questions. It includes general payment rules for all physicians, as well as definitions, required elements for particular services and details about specific categories of services and premiums. The preambles for groups of services at the beginning of certain sections of the Schedule includ...
This section outlines fee codes and associated payment rules for patient visits. These include all types of consultations and subsequent visits listed by specialty as well as counselling, psychotherapy and interviews. Physicians should select the most appropriate fee code from the section associated with their specialty designation unless they are ...
The next set of sections lists fee codes related to specific specialties and non-surgical procedures including: Nuclear Medicine Positron Emission Tomography (PET) Radiation Oncology Diagnostic Radiology Clinical Procedures associated with Diagnostic Radiological Examinations Magnetic Resonance Imaging (MRI) Diagnostic Ultrasound Pulmonary Function...
This section includes a preamble (applicable to all surgical procedures) as well as sub-sections for groupings of surgical procedures (some with their own specific preambles) including: Integumentary System Musculoskeletal System Respiratory System Cardiovascular Haematic and Lymphatic Digestive System Urogenital and Urinary Male Genital Female Gen...
(Prefix A – Out-patient; first two numbers 13 – Internal Medicine; third number -Consultation) Suffixes*: These have different meanings depending on the type of fee schedule code they are used with. Diagnostic tests B: indicates a technical fee. This provides compensation for the cost of equipment, personnel, supplies as well as performing the proc...
The Schedule should be applied in its entirety and not based on an individual service description or listing alone. In order to understand a fee code, you must consider all the elements in the Schedule in order, from general listings of characteristics of services to the specific individual fee code requirements. You may also need to consider all f...
Rules specific to an individual code. Rules applicable to a group of codes. Specific elements of assessment. Common elements of insured services. Maximum (General Preamble) Definition section of General Preamble.
The Schedule includes three levels of assessment – general, intermediate, and minor assessment (see General Preamble). Patients may present to their physician for an evaluation with a large variety of clinical conditions. The level of assessment that a physician may need to perform is determined by an individual patient’s circumstances. The hierarc...
Physicians, hospitals, and other health care providers are directed to review the Health Insurance Act, Regulation 552, and the Schedules under that regulation, for the complete text of the provisions. You can access this information at ontario.ca/laws.
Jan 20, 2021 · Effective November 1, 2020, the Hospitalist Premium and Internal Medicine Office Assessment Premium were implemented. For details on eligibility and payment criteria, refer to INFOBulletin 201106 and to the General Preamble of the Schedule of Benefits for Physician Services (the Schedule).
For many procedures that may be considered cosmetic, the Schedule requires the physician obtain prior approval from the ministry. This requirement is specifically listed in notes next to applicable fee codes and/or in Appendix D of the Schedule.
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The Ministry of Health and Long-Term Care (MOHLTC) is responsible for most physician payments in Ontario and emphasizes comprehensive care that encompasses health promotion and disease prevention as well as treatment and disease management.
