Bulletin 4744 — Additional Specialist Consultations Resubmission of Rejected Claims
Keeping health care providers informed of payment, policy or program changes
To: All Providers
Published by: Claims Services Branch, Ministry of Health
Date Issued: March 5, 2020
Claims submitted between November 1, 2019 and January 31, 2020 with service dates on or after October 1, 2019, for an additional specialist consultation for a clearly defined unrelated diagnosis, have been rejected by the medical claims payment system to the providers error report with error code 'AC1 – Maximum reached-resubmit alternate FSC'.
The medical rule that caused these rejections has been identified and a solution has been applied.
- If you submitted claims on or after February 1, 2020 for an additional specialist consultation, the system is correctly adjudicating the claims in accordance with the changes to the Schedule of Benefits effective October 1, 2019.
- If you submitted claims between November 1, 2019 and January 31, 2020 with service dates on or after October 1, 2019 for an additional specialist consultation, by the same provider, for the same patient, but for a clearly defined unrelated diagnosis within the same 12-month period and that were previously rejected to the providers' error report during this time frame, these claims can now be resubmitted. If you have already resubmitted an alternate FSC and you are eligible for payment for a consultation, please submit a Remittance Advice Inquiry to have the claims appropriately adjudicated by your local claims office.
- Submitted claims for a specialist consultation between October 1 and October 31, 2019 for service dates in October 2019 with the same diagnostic code as a previously paid consult within 24 months are not "payable pursuant to the new rules in the Schedule". Such services that were paid on the November 2019 Remittance Advice, will be subject to a Medical Claims Adjustment (MADJ). These claims will be redirected to the Remittance Advice with explanatory code 09 - Fee Schedule Code(s) used is not correct and the amount paid will be deducted. Please resubmit using appropriate assessment code(s) from the OHIP Schedule of Benefits.
- Adjustments will begin to appear on the March Remittance Advice.
- Please also note that during the MADJ 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 that were reprocessed with no change in payment will appear on the Remittance Advice (RA) 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 out to zero with no payment impact but will report on the RA for reconciliation purposes.
- The ministry has agreed in this circumstance to extend the stale dating policy for resubmission of consult FSC to August 31, 2020 to allow enough time for providers to resubmit their previously rejected claims.