OHIP Billing by Services
Case studies of OHIP dental claims
Purpose: Use this article to train billing clerks how to read dental claims and interpret HYPEMedical's NS (number of services) column correctly, and understand why each service-code combination was billed the way it was. Examples used include the ...
OHIP dental sample claims and test cases for staff training
Symptoms Use this article when staff need: claim examples for onboarding, mock training cases, rejection examples, or premium and prior approval test cases. Cause Many clerks understand the code list but still miss the billing logic. Training works ...
Core OHIP dental service code inventory for billing clerks
Symptoms Use this article when a clerk is asking: What code family am I looking at? Is this a routine code, premium code, virtual code, or prior approval code? Which codes should our team memorize first? Cause Most new dental clerks struggle because ...
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 ...
OHIP dental billing basics for hospital dental services
Symptoms Use this article when a clerk is asking: Is this dental service insured by OHIP? Can I bill this as a hospital consultation? Why did the claim reject or pay zero? What basic claim fields should I verify before submission? Cause Most dental ...
What are "Sample OHIP dental claims": successful claims, premiums, manual review, prior approval, and common rejection reasons
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, ...
Which OHIP dental service codes should billing clerks know?
Short answer The hospital dental OHIP schedule is much broader than most clerks expect. For day-to-day work, clerks should know the access/assessment codes, the premium codes, the virtual-care codes, and the Part III prior approval extraction codes ...
When do I bill dental premiums, manual review, independent consideration, or prior approval?
Short answer Use premiums when the schedule’s timing, care setting, or patient-acuity conditions are met. Use manual review when the schedule requires supporting explanation for adjudication. Use independent consideration for unlisted or specially ...
How do I bill OHIP hospital dental services correctly?
Short answer OHIP dental billing is mainly for insured dental services rendered in the hospital setting. Clerks should first confirm that the service is actually an insured hospital dental service, that the service location and documentation fit the ...
What are CT & MRI Procedures, Consults & Premiums
Summary / Description This article helps Ontario CT & MRI community clinics and billing teams build a clean “procedure catalogue” that maps clinic-facing MRI procedure names to the correct OHIP MRI service codes (base + repeats + contrast add-on). It ...
Emergency Medicine (ED) Billing FAQs (OHIP): H-Codes, Re-Assessments, Premiums, Consults, Critical Care, After-Hours Procedure Premiums, Phone Consults
SUMMARY / DESCRIPTION Quick answers for Ontario OHIP Emergency Medicine billing: which H-code to use by time period, when re-assessments are payable, how H112/H113 premiums work, how to bill ED consultations, critical care time, after-hours procedure ...
Which OHIP Special Visit Premium time period applies right now? (Quick Decision Guide)
Summary / Description Use this quick decision guide to choose the correct OHIP Special Visit Premium time window (weekdays daytime, sacrifice of office hours, weekday evening, weekend/holiday, or night). Then select the matching Travel Premium and ...
OHIP Special Visit Premiums — Quick Lookup (K990/K991/K994/K995/K998/K999/K996/K997 + Travel Premiums)
Summary / Description: One-screen quick lookup for OHIP Special Visit Premiums using K-codes (first person seen + additional persons seen) and Travel Premiums by time period. Includes the max-per-time-period rules and required chart documentation ...
Emergency Department “H” Codes – Quick Lookup (Time Period → H-Code → Fee → Key Rule)
Summary / Description: Quick lookup for Emergency Department “H” assessment codes by time period, plus ED-physician premiums and after-hours procedure premiums. Use this to pick the right H-code and confirm the key payment rules. Emergency Department ...
OHIP Emergency Department Physician Billing (EM) — H-Codes, Consultations, Critical Care, Premiums & After-Hours
Summary / Description: Use this article to bill Emergency Department physician services under OHIP. It covers time-of-day H-assessment codes, Emergency Medicine consultations, critical care, special visit premiums, ambulance detention, ...
General Preamble – Assessments (GP21 - GP39): General, Periodic, Specific & Paediatric Assessments – Definitions and Limits
Summary / Description This article explains OHIP “General Preamble” assessment types defined on pages GP21–GP39, including general, specific, paediatric, chronic disease, newborn and e-assessments, plus detention, ambulance detention and organ ...
Consultations (GP16) – OHIP Rules, Limits and Definitions for All Specialties
Summary / Description This article explains how OHIP defines a consultation, repeat consultation and limited consultation, how often consultations can be billed, and how emergency room and special surgical consultations work. It is based on the ...
Diagnostic Radiology (33) – OHIP Consults, Assessments, Components & After-Hours Premiums (2025)
Summary / Description Diagnostic radiology (33) bills for the professional interpretation and technical performance of imaging studies, plus specific consultations, second opinions, minor assessments and after-hours premiums. This article explains ...
Anaesthesia (01) – OHIP Consults, Assessments, Units & After-Hours Premiums (2025)
What does Anaesthesia (01) bill under OHIP? Anaesthesia (01) covers: Pre-anaesthetic evaluation The general anaesthesia service includes a pre-anaesthetic evaluation, the anaesthetic procedure itself, and post-anaesthetic follow-up. ...
AT3 - Which service codes qualify as virtual codes with a K301A vs. a K300A?
Virtual care claims must include one of the following tracking codes: K300A – services provided by phone K301A – services provided by video The following service codes are eligible for virtual billing when submitted with K300A (phone) or K301A ...
What are the new phone and video virtual service codes effective Dec.01,2022?
How do I bill virtual codes? Why are my K08*A codes being rejected? An excllent MOHLTC guide released on Nov. 24, 2022; introduction to new OHIP Virtual Care Services and fee codes
OTN - Telemedicine
This article has been updated on Dec 01, 2022 by ... What are the new phone and video virtual service codes effective Dec.01,2022? Expired KB article How do physicians qualify for telemedicine? To qualify physicians must sign and complete an “OHIP ...
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 ...