OHIP Explanation Codes 55 and 57

OHIP Explanation Codes 55 and 57

There are cases where OHIP determines that certain service codes were “not paid properly” on past claims. The processes that OHIP uses to fix such cases can seem to be confusing. Explanation codes 55 and 57 seem to show that OHIP pays and then takes away money.

However in these cases the OHIP claims processing system selects the entire claim (not the improperly paid service code) and reprocesses it. A single claim can include multiple fee schedule codes and all codes will be reprocessed. Services that were reprocessed with no change in payment will appear on the Remittance Advice (RA) with explanatory code ‘55-This deduction is an adjustment on an earlier account’ and ‘57-This payment is an adjustment on an earlier account’. These two transactions will net out to zero with no payment impact but will report on the RA for reconciliation purposes.

*Originally published August 8, 2020

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