Remittance advice explanatory codes and messages - expl codes

OHIP Remittance Advice Explanation Codes and Messages

OHIP Remittance Advice explanation codes clarify payment exceptions and claim-assessment results appearing on a monthly Remittance Advice statement.

These codes may also be called:

Explanation codes
Explanatory codes
Expl codes
Rejection code
Error code
Remittance Advice messages
RA codes

Use this article to search for a code and review the corresponding message.

How do I find an OHIP explanation code in HYPEMedical?

Open the Billing Cycle and search for Rejected claims.
Locate and hover over the (i) in the Expl. Codes column for the explanation to load.
Review the description associated with the code.
Compare the explanation with the submitted claim and the payment.

An explanation code describes how OHIP assessed or adjusted the claim. The appropriate follow-up depends on the service submitted, the payment received, the claim history and the applicable OHIP billing requirements.

Numeric OHIP Explanation Codes

Code	Explanation
30	Service is not a benefit of the Ontario Health Insurance Plan.
31	Not a valid network service.
32	OHIP records show that service or services on this day were claimed previously.
33	Approved.
35	OHIP records show that this rendered service was claimed previously. Used on Pay Practitioner duplicate claims.
36	OHIP records show that the service was rendered by another practitioner, group or laboratory.
37	Effective April 1, 1993, the listed benefit for this code is zero Laboratory Medicine Services units.
40	The service or a related service is allowed only once for the same patient.
41	Fee Schedule Code billed with no evidence in the supporting documentation provided.
42	Fee Schedule Code billed is included in another procedure.
45	Specialty-code restriction applies to the Fee Schedule Code.
46	Paid following a second review by a Medical Advisor.
47	Not paid following a second review by a Medical Advisor.
48	Paid as submitted. Clinical records may be requested for verification.
49	Paid according to the average fee for the service. Independent consideration may be given if clinical records or operative reports are presented.
50	Paid in accordance with the Schedule of Benefits.
51	Fee Schedule Code changed in accordance with the Schedule of Benefits.
52	Fee-for-service claim assessed by a medical consultant.
53	Fee allowed according to the appropriate item in a previous Schedule of Benefits.
54	Interim payment. Claim remains under review.
55	The deduction is an adjustment to an earlier account.
56	Claim under review.
57	This payment is an adjustment to an earlier account.
58	Claimed by another physician within the group.
59	Practitioner notification concerning WCB claims.
60	Not a benefit of the Reciprocal Medical Billing Agreement.
62	Claim assessed by an Assessment Officer.
65	Service included in an approved hospital payment.
66	Reduced according to an Alternative Payment Program funding contract.
69	Elective service paid at 75% of the OHIP Schedule of Rates.
70	OHIP records show that corresponding procedures on this day were previously claimed by another physician.
80	Technical-fee adjustment for hospitals.

A-Series Explanation Codes

Code	Explanation
AP	This payment is in accordance with legislation. A provider who disagrees with the payment may appeal to the General Manager.
AH	Not allowed in addition to a health examination.

B-Series Virtual-Care Explanation Codes

Code	Explanation
B1	Service is not eligible for payment when delivered by telephone.
B2	Paid in accordance with the OHIP Schedule of Benefits for Telephone Virtual Care Services.
B3	Patient-physician relationship requirements were not met.
B4	Virtual service is not allowed in addition to the in-person equivalent service.
B5	In-person service is not allowed in addition to the virtual equivalent service.
B6	Limited virtual-care service already paid.
B7	Comprehensive virtual-care service already paid.
B8	Service is not eligible for payment when provided virtually.

What does OHIP explanation code B1 mean?

B1 means the submitted service is not eligible for payment when it is delivered by telephone.

What does B3 mean?

B3 means the patient-physician relationship requirements were not met.

What is the difference between B4 and B5?

B4: The virtual service is not allowed in addition to its in-person equivalent.
B5: The in-person service is not allowed in addition to its virtual equivalent.

C-Series Consultation and Assessment Codes

Code	Explanation
C1	Allowed as a repeat consultation, limited consultation or midwife-requested emergency assessment.
C2	Allowed at the reassessment fee.
C3	Allowed at the minor-assessment fee.
C4	Consultation is not allowed with this service and was paid as an assessment.
C5	Allowed as a multiple-systems assessment.
C6	Allowed as a Type 2 admission assessment.
C7	An admission assessment, C003A, or general reassessment, C004A, may not be claimed by any physician within 30 days following a pre-dental or pre-operative assessment.
C8	Payment reduced to the geriatric-consultation fee because the maximum number of comprehensive geriatric consultations was reached.
C9	Allowed as inpatient interim admission orders. The initial assessment was already claimed by another physician.

D-Series Procedure and Diagnostic-Service Codes

Code	Explanation
D1	Allowed as a repeat procedure because the initial procedure was previously claimed.
D2	Additional procedures allowed at 50%.
D3	Not allowed in addition to a visit fee.
D4	Procedure allowed at 50% with a visit.
D5	Procedure already allowed. Visit fee adjusted.
D6	Payment limit for this procedure was reached.
D7	Not allowed in addition to another procedure.
D8	Allowed only with specified procedures.
D9	Not allowed to a hospital department.
DA	Maximum for this procedure was reached. Paid as a repeat or chronic procedure.
DB	Another dialysis procedure was already paid.
DC	A previously paid procedure is not allowed in addition to this procedure. The fee was adjusted to pay the difference.
DD	Not allowed because the diagnostic code is unrelated to the original eye examination.
DE	Laboratory tests were already paid. Visit fee adjusted.
DF	Corresponding fee code was not billed or was paid at zero.
DG	Diagnostic or miscellaneous services for hospital patients are not payable on a fee-for-service basis because they are included in the hospital global budget.
DH	Ventilatory support allowed with haemodialysis.
DL	Allowed as laboratory tests performed in a private office.
DM	Paid or disallowed according to Ministry policy concerning an Emergency Department Equivalent.
DN	Allowed as a pudenal block in addition to the procedure according to the stated OHIP policy.
DP	A previously paid procedure is allowed at 50% in addition to this procedure. The fee was adjusted to pay the difference.
DS	Not allowed because mutually exclusive codes were billed.
DT	Inpatient technical fee not allowed.
DR	Self-referred diagnostic services payable at 50%.
DV	Service is included in the Monthly Management Fee for long-term-care patients.
DW	A previously paid procedure is not allowed in addition to monthly management for a long-term-care patient. The fee was adjusted to pay the difference.
DX	Diagnostic code is not eligible with the Fee Schedule Code.

What does DF mean?

DF means the corresponding fee code was not billed or was paid at zero.

What does DS mean?

DS means the submitted codes are mutually exclusive and cannot be paid together.

What does DX mean?

DX means the diagnostic code submitted on the claim is not eligible with the Fee Schedule Code.

E-Series Eligibility and Version-Code Messages

Code	Explanation
E1	Service date was before the start of eligibility.
E2	Incorrect version code for the service date.
E3	Version code is not on file for the Health Number.
E4	Service date was after the eligibility termination date.
E5	Service date was not within an eligible period.
E6	Service date was after the eligibility end date. Ministry records indicate the patient is deceased.
E9	Service date was after the eligibility end date because eligibility was terminated following no response to a notice to register.
EA	Service date was not within an eligible period. Services provided on or after the twentieth of the month will not be paid unless the eligibility status changes.
EB	Coding was added or changed in accordance with the Schedule of Benefits.
EE	Assessment allowed at the full fee for a patient proceeding to hospital.
EF	Incorrect version code. Services provided on or after the twentieth of the month will not be paid unless the current version code is provided.
EN	Network billing not allowed.
EP	Payment is an adjustment to an earlier account resulting from a provider-registration update.
EV	Check the health card for the current version code.

Which explanation codes indicate a version-code problem?

The following codes relate to a Health Number version code:

E2: Incorrect version code for the service date
E3: Version code not on file for the Health Number
EF: Incorrect version code with a warning concerning services after the twentieth of the month
EV: Check the health card for the current version code

Which explanation codes indicate that the patient was not eligible?

Common eligibility-related codes include:

E1: Service date before eligibility began
E4: Service date after eligibility ended
E5: Service date outside an eligible period
E6: Eligibility ended because Ministry records indicate that the patient is deceased
E9: Eligibility ended following no response to a notice to register
EA: Service date outside an eligible period

F-Series Fracture and Additional-Payment Codes

Code	Explanation
F1	Additional fractures or dislocations allowed at 85%.
F2	Allowed in accordance with transferred care.
F3	Previous attempted reductions, open or closed, allowed at 85%.
F5	Two weeks of aftercare are included in the fracture fee.
F6	Allowed as a minor or partial assessment.
FF	Additional payment for the claim shown.

G-Series Codes

Code	Explanation
G1	Other critical or comprehensive care was already paid.
GF	Coverage lapsed. Bill the patient for future claims.

H-Series Hospital and Concurrent-Care Codes

Code	Explanation
H1	Admission assessment or emergency-department assessment already paid.
H2	Allowed as a subsequent visit because the initial visit was previously claimed.
H3	Maximum weekly fee allowed after the fifth week.
H4	Maximum weekly fee allowed to paediatricians after the sixth week.
H5	Maximum monthly fee allowed after the thirteenth week.
H6	Allowed as supportive or concurrent care.
H7	Allowed as chronic care.
H8	Hospital number and/or admission date required for an in-hospital service.
H9	Concurrent care was already claimed by another physician.
HA	Admission assessment was claimed by another physician. A hospital-visit fee was applied.
HB	Subsequent visit was already paid on the same day.
HF	Concurrent or supportive care was already claimed during the period.
HM	Invalid master number used on the service date.

What does H8 mean?

H8 means a hospital number, admission date or both are required for the submitted in-hospital service.

What does HM mean?

HM means the master number entered on the claim was not valid for the service date.

I-Series Independent Health Facility and Funding Codes

Code	Explanation
I2	Service is globally funded.
I3	Fee Schedule Code was not on the Independent Health Facility licence profile for the specified date.
I4	Records show that the service was rendered by another practitioner, group or Independent Health Facility.
I5	Service is globally funded and the Fee Schedule Code is not on the Independent Health Facility licence profile.
I6	Premium is not applicable.
I7	Claim date does not match the patient’s enrolment date.
I8	Confirmation was not received.
I9	Payment is not applicable or has expired.

J-Series Coverage and Stale-Dated Claim Codes

Code	Explanation
J1	Service date was before the effective date of OHIP coverage.
J2	Service date was after the termination date of coverage.
J3	Approved for stale-dated processing.
J5	Coverage was applied for, but premiums have not yet been paid.
J7	Claim was submitted three months after the service date.
J8	Coverage was not in effect. Services provided on or after the twentieth of the month will not be paid unless the subscriber takes corrective action.
J9	Coverage was reinstated. Submit claims routinely.

What does J7 mean?

J7 means the claim was submitted three months after the service date.

What does J3 mean?

J3 means the claim was approved for stale-dated processing.

What does J9 mean?

J9 means the patient’s coverage was reinstated and claims may be submitted routinely.

L-Series Laboratory Explanation Codes

Code	Explanation
L1	This service was paid to another laboratory.
L2	Not allowed to a medical laboratory director.
L3	Not allowed in addition to another laboratory procedure or procedures.
L4	Not allowed to attending physicians.
L5	Not allowed in addition to another procedure paid to another laboratory.
L6	A procedure was previously paid to another laboratory and is not allowed in addition to this procedure. The fee was adjusted to pay the difference.
L7	Not allowed for a referred specimen.
L8	Not to be claimed with a prenatal or fetal assessment.
L9	Laboratory services for hospital inpatients or outpatients are not payable on a fee-for-service basis because they are included in the hospital global budget.
LA	Laboratory service is funded by a special laboratory agreement.
LS	Paid in accordance with a special laboratory agreement.

M-Series Maximum and Minimum Requirement Codes

Code	Explanation
M1	Maximum fee or maximum number of services was reached for the same provider or any provider.
M2	Maximum allowance for radiographic examinations by one or more practitioners was reached.
M3	Maximum fee allowed for prenatal care was reached.
M4	Maximum fee for these services by one or more practitioners was reached.
M5	Monthly maximum was reached.
M6	Maximum fee allowed for a special-visit premium for an additional patient was reached.
MA	Maximum number of sessions was reached.
MC	Maximum number of case conferences in a 12-month period was reached.
MD	Daily maximum was exceeded.
ME	Maximum number of e-assessments was paid.
MM	Claim does not meet the requirements of the Physician Schedule of Benefits.
MN	Maximum number of occipital nerve-block sessions was reached.
MO	Maximum number of Optical Coherence Tomography services was reached.
MR	Minimum service requirements were not met.
MS	Maximum number of sleep studies in the specified period by one or more physicians was reached.
MX	Maximum of two arthroscopy R codes with E595 was reached.
MU	Maximum units exceeded.
MW	Maximum number of weeks has elapsed since payment of the initial service.
MY	Yearly maximum was exceeded.

Which code means a maximum was reached?

Common maximum-related codes include:

M1: Maximum fee or number of services
M5: Monthly maximum
MA: Maximum number of sessions
MC: Maximum number of case conferences
MD: Daily maximum
MU: Maximum units
MY: Yearly maximum

What does MR mean?

MR means the minimum service requirements were not met.

What does MM mean?

MM means the claim does not meet the requirements of the Physician Schedule of Benefits.

O-Series Obstetrical Codes

Code	Explanation
O1	Fee for obstetrical care apportioned.
O2	Previous prenatal care was already claimed.
O3	Previous prenatal care was already claimed by another physician.
O4	Office visits related to pregnancy and claimed before delivery are included in the obstetrical fee.
O5	Not allowed in addition to delivery.
O6	Medical induction or stimulation of labour is allowed once per pregnancy.
O7	Allowed as a subsequent prenatal visit because the initial prenatal visit was already claimed.
O8	Allowed once per pregnancy.
O9	Not allowed in addition to postnatal care.

P-Series Paediatric, Health Care Connect and Roster Codes

Code	Explanation
P2	Maximum fee allowed for low-birth-weight care.
P3	Maximum fee allowed for newborn care.
P4	Newborn-care or low-birth-weight-care fee is not billable with neonatal intensive care.
P5	Patient is over age for paediatric payment rates.
P6	Patient is over age for well-baby care.
P8	Health Care Connect period is greater than three months.
P9	Complex new patient.
PM	Minimum roster size was not met.

Q-Series Codes

Code	Explanation
Q7	No fee is allowed for treatment of an immediate family member.
Q8	Laboratory was not licensed to perform the test on the service date.

R-Series Health Examination and Reciprocal Billing Codes

Code	Explanation
R1	Only one health examination is allowed in a 12-month period.
R2	Ten well-baby visits are allowed up to two years of age.
R3	One well-child examination for patients aged two to five is allowed within a 12-month period.
RD	Duplicate claim paid through the Reciprocal Medical Billing System.

S-Series Surgery and Postoperative Codes

Code	Explanation
S1	Bilateral surgery completed in one stage was allowed at 85% more than the unilateral fee.
S2	Bilateral surgery completed in two stages was allowed at 85% more than the unilateral fee.
S3	Second surgical procedure allowed at 85%.
S4	Procedure fee reduced when paid with related surgery or anaesthesia.
S5	Not allowed in addition to a major surgical fee.
S6	Allowed as a subsequent procedure because the initial procedure was previously claimed.
S7	Normal pre-operative and postoperative care are included in the surgical fee.
S9	Initial procedure was not found.
SA	Surgical procedure allowed at the consultation fee.
SB	Normal pre-operative visit is included in the surgical fee. The visit was previously paid, and the surgical fee was adjusted.
SC	Not allowed because a major pre-operative visit was already claimed.
SD	Not allowed because a team or assistant fee was already claimed.
SE	Major pre-operative visit and admission assessment were previously paid. The surgery fee was reduced by the admission-assessment amount.
SF	Most Responsible Physician visit is not allowed during the postoperative period. The surgical fee was adjusted.
SV	Most Responsible Physician visit is not allowed during the postoperative period. The fee was reduced to a subsequent-visit fee.
SW	Intensive Care Unit per-diem code was paid to another physician. The Most Responsible Physician subsequent visit was reduced to a subsequent-visit fee.
SX	Intensive Care Unit per-diem code was paid to another physician. The Most Responsible Physician premium was not allowed.

T-Series Codes

Code	Explanation
T1	Fee allowed according to the surgery claim.

V-Series Visit, Assessment and Oculo-Visual Codes

Code	Explanation
V1	Allowed as a repeat assessment because the initial assessment was previously claimed.
V2	Allowed as an extra patient seen in the home.
V3	Not allowed in addition to a procedural fee.
V4	Service date was not a Saturday, Sunday or statutory holiday.
V5	Only one major oculo-visual examination is allowed during the applicable eligibility period.
V6	Allowed as a minor assessment because the initial assessment was already claimed.
V7	Allowed at the medical or specific reassessment fee.
V8	Service was paid at a lower fee according to the stated OHIP policy.
V9	Only one initial office visit is allowed within a 12-month period.
VA	Procedure fee reduced because consultation or visit fees are not allowed in addition.
VB	An additional Oculo-Visual Assessment is allowed once during the second year for patients aged 20 to 64 following a periodic Oculo-Visual Assessment.
VC	A previously paid procedure is not allowed in addition to the visit fee. The fee was adjusted to pay the difference.
VG	Only one geriatric general-assessment premium is allowed per patient during a 12-month period.
VM	An oculo-visual minor assessment is allowed only during the eligibility period following a major oculo-visual examination.
VN	Allowed as a major oculo-visual examination for a senior with a medical condition.
VP	Allowed only with a special visit.
VR	Visit reduced because the premium was not applicable.
VS	Service date was a Saturday, Sunday or statutory holiday.
VX	Complexity premium is not applicable to the visit fee.

What does V8 mean?

V8 means the service was paid at a lower fee according to the applicable OHIP policy.

What does V5 mean?

V5 applies to major oculo-visual examinations. The source description states:

One examination during a 12-month period for patients under 19 or over 65 with a medical condition
One examination during an 18-month period for patients over 65 without a medical condition

What is the difference between V4 and VS?

V4: The service date was not a Saturday, Sunday or statutory holiday.
VS: The service date was a Saturday, Sunday or statutory holiday.

W-Series Warning Codes

Code	Explanation
W3	Warning: The service date is older than three months.
W4	Warning: Service Location Indicator code is missing.

Does W3 mean the claim was rejected?

The source identifies W3 as a warning that the service date is older than three months. Review the payment and claim status shown on the Remittance Advice before deciding what follow-up is required.

X-Series Diagnostic Imaging Codes

Code	Explanation
X2	Gastrointestinal tract service includes cine and videotape.
X3	Gastrointestinal tract service includes a survey film of the abdomen.
X4	Only one Bone Mineral Density service is allowed within a 36-month period for a low-risk patient.
X5	Only one Bone Mineral Density service is allowed within a 12-month period for a high-risk patient.
X6	Only one Bone Mineral Density service is allowed within a 60-month period for a low-risk patient.

Frequently Asked Questions

What is an OHIP Remittance Advice explanation code?

An OHIP Remittance Advice explanation code is a code or message used to clarify how a submitted claim was approved, adjusted, reduced, reviewed or not paid.

Where do I find OHIP explanation codes?

Explanation codes appear beside applicable claims or services on the monthly OHIP Remittance Advice report.

Which code means the claim was approved?

Code 33 means Approved.

Which codes may indicate a duplicate claim?

Duplicate or previously claimed services may be identified by:

32: Service or services on the same day were claimed previously
35: Rendered service was previously claimed on a Pay Practitioner claim
36: Service was rendered by another practitioner, group or laboratory
58: Claimed by another physician in the group
70: Corresponding procedure was previously claimed by another physician
RD: Duplicate paid through the Reciprocal Medical Billing System
HB: Subsequent visit already paid on the same day

Which code means the Fee Schedule Code was changed?

Code 51 means the Fee Schedule Code was changed in accordance with the Schedule of Benefits.

Code EB also indicates that coding was added or changed in accordance with the Schedule of Benefits.

Which code means the claim was paid according to the Schedule of Benefits?

Code 50 means the claim was paid in accordance with the Schedule of Benefits.

Which code means the payment was adjusted?

Adjustment-related codes include:

55: Deduction adjusting an earlier account
57: Payment adjusting an earlier account
EP: Adjustment caused by a provider-registration update
VC: Fee adjusted because a previously paid procedure was not allowed with the visit
DC: Fee adjusted to pay the difference between procedures
DP: Fee adjusted when a previous procedure was allowed at 50%

Which code means the claim is under review?

54: Interim payment while the claim is under review
56: Claim under review

Which code means OHIP may request clinical records?

Code 48 means the claim was paid as submitted, but clinical records may be requested for verification.

Which code refers to independent consideration?

Code 49 means the service was paid according to the average fee. Independent consideration may be given when supporting clinical records or operative reports are presented.

Which codes indicate that a maximum was reached?

Maximum-related codes include:

M1: Maximum fee or number of services
M2: Maximum radiographic examinations
M3: Maximum prenatal-care fee
M4: Maximum fee for specified services
M5: Monthly maximum
MA: Maximum sessions
MC: Maximum case conferences
MD: Daily maximum
ME: Maximum e-assessments
MU: Maximum units
MY: Yearly maximum

Which code means a service is not an OHIP benefit?

Code 30 means the service is not a benefit of OHIP.

Other program-specific “not a benefit” messages include:

60: Not a benefit of the Reciprocal Medical Billing Agreement
DX: Diagnostic code is not eligible with the Fee Schedule Code
B1: Not eligible when delivered by telephone
B8: Not eligible when delivered virtually

Which code indicates a stale-dated claim?

J7: Claim submitted three months after the service date
J3: Approved for stale-dated processing
W3: Warning that the service date is older than three months

Which codes relate to virtual care?

Virtual-care codes include:

B1: Not eligible by telephone
B2: Paid under the telephone virtual-care rules
B3: Patient-physician relationship requirements not met
B4: Virtual service not allowed with the in-person equivalent
B5: In-person service not allowed with the virtual equivalent
B6: Limited virtual-care service already paid
B7: Comprehensive virtual-care service already paid
B8: Service not eligible virtually

Which codes indicate an eligibility problem?

Eligibility-related messages include:

E1: Before eligibility began
E4: After eligibility ended
E5: Outside an eligible period
E6: Eligibility terminated because Ministry records indicate the patient is deceased
E9: Eligibility terminated following no response to a registration notice
EA: Service date outside an eligible period
J1: Before coverage took effect
J2: After coverage ended
J8: Coverage not in effect

Which codes relate to the Health Number version code?

E2: Incorrect version code
E3: Version code not on file
EF: Incorrect version code with an eligibility warning
EV: Check the health card for the current version code

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OHIP Remittance Advice Explanation Codes - expl codes