O. Reg. 344/01: GENERAL

 

ONTARIO regulation 344/01

made under the

health insurance act

Made: August 29, 2001
Filed: August 30, 2001
Printed in The Ontario Gazette: September 15, 2001

Amending Reg. 552 of R.R.O. 1990

(General)

Note: Since the end of 2000, Regulation 552 has been amended by Ontario Regulations 14/01, 66/01, 183/01, 250/01, 272/01, 306/01 and 322/01.  Previous amendments are listed in the Table of Regulations published in The Ontario Gazette dated January 20, 2001.

1. Section 38.0.1 of Regulation 552 of the Revised Regulations of Ontario, 1990 is revoked and the following substituted:

38.0.1 (1) The following circumstances are prescribed for the purposes of paragraph 7 of subsection 18 (2) of the Act:

1. The General Manager is of the opinion that the account for the insured service has not been submitted in accordance with the Act and the regulations.

2. The General Manager is of the opinion that the fee code used by a physician or the amount claimed by a practitioner in the account submitted for payment is incorrect in the circumstances.

3. The General Manager is of the opinion that the insured service for which an account has been submitted was provided in circumstances in which no payment or a reduced payment is to be made, according to the Act, the regulations or the schedule of benefits.

4. The General Manager is of the opinion that the account submitted by a physician for payment includes two or more fee codes that reflect, in whole or in part, the provision of a single insured service rendered to an insured person in circumstances in which the service is more accurately described by only one fee code.

5. The General Manager is of the opinion that the account submitted by a practitioner for payment includes two or more claims that reflect, in whole or in part, the provision of a single insured service rendered to an insured person in circumstances in which the service is more accurately described by only one fee code.

6. The General Manager is of the opinion,

i. that an account submitted for payment by a physician includes a fee code for a service (the “billed service”) that is described in the schedule of benefits as an element of an insured service (the “insured service”), and

ii. that the insured service was rendered by another physician to the same person as the billed service was rendered and with respect to the same medical circumstances.

(2) The following circumstances are prescribed for the purposes of paragraph 5 of subsection 39.1 (6) of the Act:

1. The applicable committee is of the opinion that the account for the insured service has not been submitted in accordance with the Act and the regulations.

2. The applicable committee is of the opinion that the fee code used by a physician or the amount claimed by a practitioner in the account submitted for payment is incorrect in the circumstances.

3. The applicable committee is of the opinion that the insured service for which an account has been submitted was provided in circumstances in which no payment is to be made, according to the Act, the regulations or the schedule of benefits.

4. The applicable committee is of the opinion that the account submitted by a physician for payment includes two or more fee codes that reflect, in whole or in part, the provision of a single insured service rendered to an insured person in circumstances in which the service is more accurately described by only one fee code.

5. The applicable committee is of the opinion that the account submitted by a practitioner for payment includes two or more claims that reflect, in whole or in part, the provision of a single insured service rendered to an insured person in circumstances in which the service is more accurately described by only one fee code.

6. The applicable committee is of the opinion,

i. that an account submitted for payment by a physician includes a fee code for a service (the “billed service”) that is described in the schedule of benefits as an element of an insured service (the “insured service”), and

ii. that the insured service was rendered by another physician to the same person as the billed service was rendered and with respect to the same medical circumstances.

(3) In this section,

“fee code” means fee schedule code as listed in the schedule of benefits.

2. This Regulation shall be deemed to have come into force on April 1, 1998.