Bulletin 250803 — Medical Claims Adjustment for Paediatric Age Premium Payments
Claims assessed in July 2025 were reprocessed to calculate the Paediatric Age Premium.
To: All Physicians
Category: Physician services
Written by: Claims Services Branch, Health Programs and Delivery Division
Date issued: August 29, 2025
Bulletin Number: 250803
Background
An issue was identified on the August 2025 Remittance Advice (RA), where Paediatric Age Premiums were not paid or reported for claims assessed in July 2025 with service dates on or after July 1, 2024. This may have resulted in incorrect recoveries and negative balances on the August RA for some providers.
Medical Claims Adjustment (MADJ)
A Medical Claims Adjustment (MADJ) has been performed to reprocess the impacted claims. Physicians can expect to see adjustments for Paediatric Age Premiums on the September 2025 RA.
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 other than correcting the paediatric age premium and will report on the RA for reconciliation purposes.
Claim items that are reprocessed and are not eligible for payment in accordance with Schedule of Benefits for Physician Services, or approved at an adjusted rate, will be accompanied with one of the following explanatory codes:
| Explanatory Code | Description |
|---|---|
| 66 | Reduced per Alternative Payment Program (APP) Funding Contract |
| 70 | OHIP records show corresponding procedure(s) on this day claimed previously by another physician |
| 80 | Technical fee adjustment for hospitals |
| D2 | Additional procedures allowed at 50% |
| D3 | Not allowed in addition to visit fee |
| 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 |
| DF | Corresponding fee code was not billed or paid at zero |
| H1 | Admission assessment or Emergency department assessment already paid |
| M1 | Maximum fee allowed or maximum number of service has been reached same/any provider |
| S3 | Second surgical procedure allowed at 85% |
| S7 | Normal pre-operative and post-operative care included in surgical fee |
| SB | Normal pre-operative visit included in surgical fee-visit fee previously paid-surgical fee adjusted |
| SF | Most Responsible Physician (MRP) visit not allowed during post- operative period-surgical fee adjusted |
| SV | MRP visit not allowed during post-operative period-fee reduced to subsequent visit fee |
| SX | ICU per diem code paid to another physician, MRP premium not allowed |
| V3 | Not allowed in addition to procedural fee |
No action is required by physicians. The ministry has implemented a solution to ensure paediatric age premiums for eligible claims will be correctly paid and reported going forward.
Keywords/Tags
Paediatric Age Premium, MADJ, Remittance Advice (RA), Claims Reprocessing, Payment Adjustment
Contact Information
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