Claim submissions for E079A, K900A, and re-processing for palliative care special premium accumulations

To: All physicians
Category: Physician Services, Primary Health Care Services
Written by: Physician Relations & Contract Oversight Branch
Date issued: December 1, 2023
Bulletin Number: 231201

Background

The Ministry of Health and the Ontario Medical Association have been working together to implement the 2021 Physician Services Agreement.

As described in INFOBulletin 231101, adjustments to the processing of previously submitted claims for services provided virtually via video and telephone have been made.

Update: medical claims adjustments

A medical claims adjustment was required to reprocess claims for ‘E079A smoking cessation: initial discussion with patient’. The updated payment rules for this were implemented November 1, 2023, with an effective date of December 1, 2022.

Also included was the reprocessing of claims for ‘K900A - Biosimilar Support Fee’. The updated payment rules for this were implemented November 1, 2023, with an effective date of March 31, 2023.

Additionally, further reprocessing was required to accumulate the following services towards eligible physicians’ palliative care special premiums. The updated payment rules for this were implemented November 1, 2023, retroactive to December 1, 2022. This adjustment did not require the adjustment of the following claims as they were correctly paid:

  • A945A - Special palliative care consultation
  • C945A - Special palliative care consultation
  • K023A - Palliative care support

Claims for smoking cessation: initial discussion with patient (E079A) processed between December 1, 2022, and October 31, 2023, and biosimilar support fee (K900A) processed between March 31, 2023, and October 31, 2023, were subject to the adjustment. These claims have been adjusted in accordance with the Schedule of Benefits.

As per INFOBulletin 231101, adjustments for the following claims will appear on the December 2023 Remittance Advice:

  • Smoking cessation: initial discussion with patient (E079A) submitted before the implementation date of November 1, 2023, with service dates between December 1, 2022, and October 31, 2023, have been reprocessed. Any E079A billed without the same modality indicator as the required service it was submitted with was adjusted to conform to the payment rules.
  • Biosimilar support fee (K900A) submitted between March 31, 2023, and October 31, 2023, have been reprocessed to allow payment for services submitted with a modality indicator that may have previously been paid at $0.00 with an explanatory code of ‘B8 - Service Not Eligible for Payment Virtually’.

Please note during the medical claims adjustments process, the claims processing system selects an entire claim and reprocesses it. A single claim can include multiple fee codes and all codes will be reprocessed.

Please note that claims reprocessed with no change in payment will appear on the Remittance Advice 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 to zero with no payment impact but will be reported on Remittance Advice for reconciliation purposes.

No action is required on the part of the physician.

Keywords/Tags

Virtual Care; Palliative Care; Special Premiums; Biosimilar; Smoking Cessation; E079A; K900A; A945A; C945A; K023A; MADJ; Medical Claims Adjustments; Adjustments

Contact information

Do you have questions about this INFOBulletin? Email the Service Support Contact Centre or call 1-800-262-6524. Hours of operation: 8:00 a.m. to 5:00 p.m. Eastern Monday to Friday, except holidays.