OHIP billing rejections, explanatory codes, and payment adjustments are a common part of medical billing, even for experienced physicians. While some are simply informational, others can delay payment or result in lost revenue if not addressed promptly.
Understanding the most common OHIP billing errors can help reduce claim rejections, improve billing accuracy, and recover revenue more efficiently.
In this blog, we’ll review 10 of the most common OHIP billing errors and explanatory codes, explain what causes them, and outline practical steps to correct them.
Understanding OHIP Billing Errors vs. Explanatory Codes
Billing claims that are incorrectly submitted will come back rejected, leading to either no payment or an adjusted payment amount. These errors are typically categorized as:
- 3-digit alphanumeric error codes: Found in the Error Report (ER).
- 2-digit alphanumeric explanatory codes: Found in the Remittance Advice (RA).
It’s essential to identify and correct these errors within three months of the service date to avoid delays and ensure proper payment.
Most Common OHIP Billing Errors Physicians Encounter
In our experience working with Ontario physicians, the following OHIP billing errors are among the most common and the most likely to impact revenue if left unresolved. While some errors are straightforward to correct, others require additional investigation, specific documentation, or a thorough understanding of OHIP billing rules and claims processes.
1. EH2 – Invalid Version Code
What it means & common causes
The health card version code submitted with the claim does not match the version currently on file with the Ministry of Health. This commonly occurs when a patient has recently renewed or replaced their health card and the updated version code has not been entered into your EMR.
How to fix it
Verify the patient’s health card and update the version code in your EMR before resubmitting the claim. Encouraging patients to present their most recent health card at each visit can help prevent this error.
Many physicians may see EH4- No Valid Coverage, alongside EH2- Invalid Version Code. In this case, the physician would not be able to rebill this claim as the patient had no valid coverage during this service date and would need to charge the patient out-of-pocket.
Related Resource: Understanding and Correcting EH2 and VH9 OHIP Billing Errors
2. AT3 – No Physician-Patient Relationship Exists
What it means & common causes
The submitted fee code requires an eligible physician-patient relationship, but OHIP has no record of one. This often occurs when a patient is seen for a virtual visit and is not enrolled in your practice or has not been seen in person for the last 24 months.
How to fix it
Confirm the patient’s enrolment status and ensure the service billed is appropriate for the existing physician-patient relationship. You would then rebill the claim with ‘A101- Limited Virtual Care by Video’ or ‘A102 – Limited Virtual Care by Phone’ based on the nature of the visit.
3. A2A – Patient Age Does Not Correspond to Fee Code
What it means & common causes
The fee schedule code billed does not match the patient’s age eligibility requirements. This often happens when a physician bills for a periodic health visit, like ‘K130- Periodic health visit’, for a patient who’s 15 years old, or ‘Q015- Newborn Episodic Fee’ for a patient over 1 year old.
How to fix it
Verify the patient’s date of birth and ensure you’ve selected the correct fee code based on the Schedule of Benefits, and rebill with the appropriate age-based fee code if applicable.
4. EP1 – Enrolment Transaction Not Allowed
What it means & common causes
An enrolment or roster transaction cannot be processed because it does not meet Ministry enrolment requirements. This may occur if the patient is already enrolled with another physician, the submitted service date falls outside of the patient’s valid enrollment or termination period, or the enrollment transaction cannot be processed due to existing restrictions or pending files.
How to fix it
Review the enrolment claim, confirm patient eligibility, and verify that all required information has been submitted correctly before attempting to submit the claim again.
5. M1 – Maximum Fee Allowed Reached
What it means & common causes
The maximum number of billable services or payments allowed for the fee code has already been reached for the patient during the applicable time period. For example, if a diabetic patient was billed for ‘K030- Diabetes Management Assessment’ more than the allowable amount per 12-month period, the physician would receive this explanatory code on their RA.
How to fix it
Review the Schedule of Benefits and confirm whether the service has already been billed or whether frequency limits have been exceeded. Resubmit alternate fee code or write-off fee code if not payable.
6. VH9 – Health Number Not Registered
What it means & common causes
The health card number submitted is not recognized by the Ministry of Health. This may result from an incorrect health card number, an expired card, or a patient who is not currently eligible for OHIP coverage.
How to fix it
Verify the patient’s health card information and confirm eligibility before resubmitting the claim. If necessary, ask the patient to contact ServiceOntario to update their health coverage.
Related Resource: Understanding and Correcting EH2 and VH9 OHIP Billing Errors
7. VJ7 – Stale Dated Claim
What it means & common causes
This means the claim was submitted more than 3 months after the date of service. OHIP automatically rejects these claims unless there are extenuating circumstances as to why the claim(s) were not submitted within the 3-month window.
How to fix it
Check the service date and ensure the date of service entered was not a typo. If you simply entered the wrong date, update it and resubmit the claim. If the date is correct and the claim genuinely missed the 3-month submission window, you must follow the Stale-Dated Claim process to request an exception.
8. PAA – No Initial Fee Previously Paid
What it means & common causes
The claim includes a subsequent or follow-up service that requires a previously paid initial assessment or consultation, but no eligible initial fee is on record. For example, if ‘K039- Smoking Cessation Follow Up’ was billed but the initial visit, ‘E079- Smoking Cessation Initial Visit’, wasn’t paid previously, this claim would come back errored.
How to fix it
Confirm that the required initial service was previously submitted and paid. If the initial claim was rejected or has not yet been processed, resolve that claim before resubmitting the subsequent service. In the case of smoking cessation, you would rebill the claim as E079.
9. R1 – Only One Health Exam Allowed in 12 months
What it means & common causes
The patient has already received an eligible health examination within the allowable 12-month period (K017, K130, K131, K132 or K133).
How to fix it
Review the patient’s billing history before submitting another periodic health examination. If medically necessary services were provided, consider whether a different assessment code is more appropriate.
10. I6 – Premium Not Applicable
What it means & common causes
The premium submitted is not payable because the service does not meet the eligibility requirements for that premium. This usually occurs due to the patient not being enrolled for the service provided.
How to fix it
Review the premium eligibility requirements in the Schedule of Benefits to ensure all billing criteria have been met. If the premium was applied in error, resubmit the claim without the premium or with the appropriate premium code, if applicable.
Explanatory Codes That Don’t Require Action
Many physicians spend time investigating explanatory codes that simply indicate how a claim was processed and do not require any action to be taken.
Examples include:
- 30 – Service fee code processed
- 35 – Service already claimed previously
- B2 – Virtual care paid according to Ministry rules
- I2 – Paid at 30% due to global funding
- 55/57- This deduction is an adjustment on an earlier account.
Understanding what these codes mean can save valuable administrative time.
Best Practices to Reduce Billing Errors
While not every billing error can be avoided, implementing a few proactive habits can significantly improve claim acceptance, reduce administrative work, and help ensure you’re capturing all eligible revenue. Consider incorporating the following best practices into your billing workflow:
- Verify health card and version code information regularly to ensure patient information is current before submitting claims and to avoid delays in payment.
- Review referral numbers before submission to confirm they are valid and meet OHIP billing requirements.
- Monitor service restrictions to avoid submitting claims that exceed eligible billing limits.
- Ensure all required fee code combinations are submitted on the same claim when applicable, as missing associated fee codes or premiums can result in reduced or rejected payments.
- Double-check the diagnostic code attached to the claim, as incorrect diagnostic codes, or in some cases, no diagnostic codes, will lead to claim errors.
- Review your Error and Remittance Advice (RA) reports regularly to identify rejected claims, payment adjustments, and recurring billing issues that require follow-up.
- Analyze billing trends over time or work with a billing support team to identify recurring errors, improve billing processes, and reduce future claim rejections.
Regularly reviewing your billing processes and resolving recurring issues early can have a lasting impact on your practice’s financial performance.
How DoctorCare Can Help
Billing errors can impact cash flow, increase administrative burden, and result in missed revenue opportunities. DoctorCare’s Billing Care service helps physicians identify recurring billing issues, manage claim corrections, and optimize billing processes to improve claim acceptance and revenue capture.
Contact our team to learn how we can support your practice.
