Short answer
These examples are training cases for clerks. They are not legal opinions and they do not replace the current OHIP schedule, fee master, or ministry adjudication. Use them to teach staff how to think through setting, documentation, premium eligibility, manual review, and prior approval. The logic below is based on the Ontario dental schedule, Ontario technical specifications, and Ontario billing bulletins.
Scenario: A patient is referred by a physician to the hospital oral surgeon for a complex in-hospital assessment. The dentist performs the consultation in the hospital and records a separate consultation note.
Suggested code: T650
Expected result: Routine payable consultation, assuming no same-day duplicate by the same dentist and the service truly occurred in hospital.
Why: T650 is the hospital consultation code and the schedule limits same-day excess billing.
Scenario: The same patient returns within 12 months for reassessment of the same diagnosis in hospital outpatient follow-up.
Suggested code: T651
Expected result: Payable follow-up assessment if frequency and same-diagnosis rules fit.
Why: T651 is the follow-up assessment code within 12 months for the same diagnosis.
Scenario: A patient was seen previously by the dentist in hospital and is later readmitted. The dentist attends the patient in bed, reassesses the dental condition, and records a progress note.
Suggested code: T652
Expected result: Payable hospital visit if the schedule’s admitted-bed and prior-consult/procedure context is met.
Why: T652 is for the admitted bed patient visit after the qualifying prior encounter/surgery context.
Scenario: An emergency impacted tooth surgery begins Saturday evening at 8:30 p.m. in hospital.
Suggested codes: Base surgical code such as T905/T906 as appropriate, plus T809
Expected result: Base surgical service plus 30% premium if the surgery is non-elective and the timing condition is met.
Why: T809 applies when a non-elective surgical procedure starts after 5:00 p.m. and before midnight, or on a weekend/holiday.
Scenario: A qualifying emergency hospital dental surgical procedure starts at 2:15 a.m.
Suggested codes: Base surgical code plus T810
Expected result: 50% premium if the service is non-elective and begins between midnight and 7:00 a.m.
Why: T810 is the overnight non-elective surgical premium.
Scenario: A hospital-based dentist performs a virtual consultation while located in a public acute-care hospital, documents start and stop times, and the patient is remote. The consult happens on a statutory holiday at 7:00 p.m.
Suggested codes: T655 plus T814 if the premium condition applies
Expected result: Potentially payable if all virtual-care conditions are met.
Why: Ontario made T655/T656/T814-T816 permanent, and the schedule requires the dentist’s hospital location plus start/stop time documentation.
Scenario: A patient presents urgently with a same-day consultation and extraction plan requiring odontectomy. The dentist submits the consultation with documentation explaining the emergency and why same-day consultation was necessary.
Suggested codes: T650 plus the appropriate odontectomy code, with manual review/supporting documentation workflow
Expected result: May be paid after review if the emergency or exceptional rationale is properly documented.
Why: The schedule specifically requires supporting documentation for same-day T650 with odontectomy; without it, the claim is not paid.
Scenario: A rare hospital dental surgical procedure does not fit a listed code cleanly.
Suggested code: T800, with detailed operative explanation and supporting comparison logic
Expected result: Independent consideration, not automatic routine payment.
Why: T800 is the schedule’s route for other dental and oral and maxillofacial surgery procedures not listed in the schedule.
Scenario: A medically necessary hospital case involves Part III impacted tooth removal. OHIP prior approval is obtained before the service date, and the surgery is completed within the approved timeframe.
Suggested codes: Appropriate Part III code such as T905/T906/T907, depending on the operative facts
Expected result: Payable if hospitalization is medically necessary, prior approval was properly granted, and the claim matches the approval.
Why: Part III services require medically necessary hospitalization and prior approval, and the approved procedure must be completed within one year.
Scenario: Clerk bills a T650 consultation along with a prior-approved Part III odontectomy service.
Suggested outcome: Base Part III service may be payable, but T650 should be expected at zero.
Why: The schedule says T650 is zero when rendered in conjunction with Part III procedures for which prior approval has been granted.
Scenario: Dentist sees the patient in a private office physically located in the hospital building and bills T650.
Expected result: Likely not payable as T650.
Why: The schedule says a private dental office situated in a hospital is not considered “in a hospital” for consultation billing purposes.
Scenario: Same dentist bills two T651 services for the same patient on the same day.
Expected result: Excess billing payable at zero.
Why: Any T650 or T651 in excess of one per patient per day per dentist is payable at zero.
Scenario: T655 submitted but the chart does not show start and stop times.
Expected result: Not eligible for payment.
Why: The schedule requires start and stop times in the patient record for these virtual services.
Scenario: T643 is billed in a context where the schedule expects special justification, but no surgeon letter accompanies the claim.
Expected result: Risk of zero payment.
Why: The schedule indicates some assistant claims require the surgeon’s explanation for independent consideration or they will be paid at zero.
Scenario: A valid claim is submitted after the three-month submission window.
Expected result: Risk of stale-date rejection or extra corrective work.
Why: Ontario moved the claims submission period for in-province OHIP fee-for-service insured and related services to three months.
When building clerk training, classify every example into one of five buckets:
routine payable,
payable with premium,
payable after manual review,
payable only with prior approval,
and likely reject/zero-pay.
That classification method mirrors real adjudication behavior better than memorizing codes alone. It also makes a Zoho Answer Bot easier to train because staff tend to ask questions in scenario form, not in pure code form.
Schedule of Benefits - Dental Services under the Health Insurance Act.
Ontario technical specifications for specialized submissions and manual review handling.
Ontario eSubmit and RAI guidance.
Ontario claim submission timeframe bulletins.
Ontario 2025 dental bulletin confirming permanent virtual dental codes.