Bulletin 240607 — PSA related medical claims adjustment: E098A
Update: Gastroenterology Chronic Disease Assessment Premium - E098A payments were reprocessed by a Medical Claims Adjustment.
To: Physicians
Category: Physician Services
Written by: Claims Services Branch, Health Programs and Delivery Division
Date issued: June 18, 2024
Bulletin Number: 240607
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 E098 - Gastroenterology Chronic Disease Assessment Premium were implemented on April 1, 2024, with an effective date of April 1, 2023. Refer to INFOBulletin 240401 for additional information.
As a result, a Medical Claims Adjustment (MADJ) was required to reprocess related claims.
Medical claims adjustment processing
Gastroenterology Chronic Disease Assessment Premium (E098A) claims assessed between April 1, 2023 and April 1, 2024 with service dates between the same dates were subject to being adjusted by the medical claims adjustment.
The claims system will reprocess these claims in accordance with the schedule. The adjustments will begin to appear on the June 2024 Remittance Advice (RA).
All claims submitted with these FSCs have been corrected to conform with the payment rules.
Please note during the medical claims adjustment process, the claims processing system selects an entire claim and reprocesses it. A single claim can include multiple fee schedule codes, and all codes will be reprocessed.
Claims for E098A submitted with ineligible diagnostic codes will appear on the RA paid at zero dollars with explanatory code ‘DX – diagnostic code is not eligible with FSC’. Physicians may need to resubmit with an eligible diagnostic code, if applicable, or the appropriate fee schedule code for the service provided.
Claim items that are reprocessed and are not eligible for payment in accordance with the schedule will be accompanied with the explanatory code ‘VX - Complexity premium not applicable to visit fee’.
Keywords/Tags
Physician Services Agreement; PSA; Physicians; Payments; E098A; Gastroenterology Chronic Disease Assessment Premium; Medical Claims Adjustment; MADJ; FSC;
Contact information
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