Update: Congestive heart failure premium E088A payments were reprocessed by a Medical Claims Adjustment.

To: All Physicians
Category: Physician Services
Written by: Claims Services Branch; Health Programs and Delivery Division
Date issued: February 6, 2024
Bulletin Number: 240202

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 230310, permanent adjustments to fee schedule codes (FSCs) within the Schedule of Benefits for Physician Services (the schedule) have been made effective April 1, 2023.

The payment rules for FSC E088A - Congestive heart failure premium were implemented on December 1, 2023, with an effective date of April 1, 2023. Refer to INFOBulletin 231203 for additional information.

As a result, a Medical Claims Adjustment (MADJ) was required to reprocess related claims.

Note: No action is required on the part of the physician.

Medical claims adjustment processing

  1. Congestive heart failure premium (E088A) claims assessed between April 1, 2023 and November 30, 2023, with service dates between the same dates were subject to being adjusted by the MADJ.
  2. The claims system will reprocess these claims in accordance with the schedule. The adjustments will begin to appear on the February 2024 Remittance Advice (RA).
  3. All claims submitted with these FSCs have been corrected to conform with the payment rules.
  4. Please note during the MADJ process, the claims processing system selects an entire claim and reprocesses it. A single claim can include multiple FSCs and all codes will be reprocessed.
  5. Claims reprocessed with no change in payment will appear on the RA with explanatory codes 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 $0 with no payment impact, but will report on the RA for reconciliation purposes.
  6. Claim items that are reprocessed and are not eligible for payment in accordance with the schedule will be accompanied with one of the following explanatory codes:
    • DF – corresponding fee code was not billed or paid at zero
    • D7 – not allowed in addition to other procedure
    • DC – procedure paid previously not allowed in addition to this procedure fee adjusted to pay the difference
    • DX – diagnostic code is not eligible with FSC

Keywords/Tags

Physician Services Agreement; PSA; Physicians; Payments; E088A; Congestive Heart Failure; Medical Claims Adjustment; MADJ; FSC;

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.