OHIP dental premiums, manual review, independent consideration, and prior approval

OHIP dental premiums, manual review, independent consideration, and prior approval

Symptoms

Use this article when a clerk is asking:

  • Does this dental claim qualify for an OHIP premium?

  • Does this claim need manual review?

  • Should I use T800?

  • Does this Part III dental claim need prior approval?

  • Why did T650 pay zero with a prior-approved dental surgery claim?

Cause

These issues usually arise when the service is not routine. Common triggers are:

  • after-hours or overnight surgery,

  • ICU or special-timing consultation/visit premiums,

  • virtual dental services,

  • unlisted procedures,

  • or Part III procedures that require prior authorization.

Resolution

A. Premiums

T809 and T810 — non-elective surgical premiums

Use these only when the base service is a qualifying non-elective surgical procedure:

  • T809 — 30% premium when the service begins after 5:00 p.m. and before midnight, or on a Saturday, Sunday, or holiday.

  • T810 — 50% premium when the service begins between midnight and 7:00 a.m.

T814, T815, T816 — virtual consultation/visit premiums

These are tied to qualifying virtual dental services:

  • T814 — 30% premium for consultation/visit between 5:00 p.m. and midnight, or on a Saturday, Sunday, or holiday.

  • T815 — 30% premium for consultation/visit to a patient in an intensive care facility.

  • T816 — 50% premium for consultation/visit between midnight and 7:00 a.m.

Ontario also confirmed that T655, T656, T814, T815 and T816 are now included on a permanent basis.

B. Virtual dental services

T655 and T656

Use virtual dental codes only when the schedule conditions are met. A key rule for clerks is documentation:

  • the service must be documented in the patient record,

  • and the chart must include start and stop times,

  • otherwise the service is not eligible for payment.

C. Manual review

Manual review is used when the claim needs ministry attention and supporting material. Ontario’s technical specifications define the Manual Review Indicator as a trigger that brings the claim to the ministry’s attention for review of additional documentation.

A practical dental example is:

  • same-day T650 with odontectomy — this requires supporting documentation for adjudication.

D. Independent consideration

T800

Use T800 when the dentist performed an insured dental surgical service that does not map properly to a listed schedule code and must be assessed individually. This is not routine billing. It is a special pathway for complex or unlisted dental surgical claims.

E. Prior approval / preapproval

Part III dental services generally require:

  • medically necessary hospitalization,

  • and prior approval from the OHIP Dental or Medical Consultant.

Ontario’s technical specifications list these dental code ranges as requiring prior authorization:

  • T901–T912

  • T925–T928

  • T936

  • T950

A key clerk rule:

  • when T650 is billed in conjunction with Part III procedures for which prior approval has already been granted, the amount payable for T650 is zero.

Examples

Example 1 — payable premium
Emergency non-elective dental surgery starts at 8:00 p.m. on Saturday. Bill the base surgical code plus T809 if all conditions are met.

Example 2 — overnight premium
Emergency non-elective dental surgery starts at 2:00 a.m. Bill the base code plus T810 if the service qualifies.

Example 3 — virtual claim missing times
T655 billed but the chart does not show start and stop times. Expect payment trouble.

Example 4 — independent consideration
Rare hospital dental surgery does not match a listed code cleanly. Consider T800 with detailed supporting explanation.

Example 5 — prior-approved Part III with T650 added
If a clerk adds T650 to a prior-approved Part III procedure, expect T650 to pay zero.