O. Reg. 362/02: GENERAL

 

ONTARIO regulation 362/02

made under the

health insurance act

Made: December 11, 2002
Filed: December 13, 2002
Printed in The Ontario Gazette: December 28, 2002

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

(General)

Note: Since the end of 2001, Regulation 552 has been amended by Ontario Regulations 23/02, 56/02, 57/02, 61/02, 169/02, 176/02, 234/02, 302/02, 314/02 and 361/02.  Previous amendments are listed in the Table of Regulations published in The Ontario Gazette dated January 19, 2002.

1. Sections 38.3 and 38.4 of Regulation 552 of the Revised Regulations of Ontario, 1990 are revoked and the following substituted:

38.3 (1) In this section,

“electronic data transfer” means a method approved by the Ministry of Health and Long-Term Care for electronically transferring information.

(2) It is a condition of payment that the following claims be submitted by electronic data transfer: 

1. A claim for the cost of an insured service rendered by a physician, practitioner or health facility, if the physician, practitioner or health facility was first assigned an Ontario Health Insurance Plan identification number on or after January 1, 2003.

2. A claim for the cost of a laboratory service that is an insured service under section 22, if the medical director of the laboratory was first assigned an Ontario Health Insurance Plan identification number on or after January 1, 2003.

(3) It is a condition of payment that the following claims be submitted in a machine readable form acceptable to the Ministry of Health and Long-Term Care:

1. A claim for the cost of an insured service rendered by a physician, practitioner or health facility, if the physician, practitioner or health facility was assigned an Ontario Health Insurance Plan identification number on or after January 1, 1993 and before January 1, 2003.

2. A claim for the cost of a laboratory service that is an insured service under section 22, if the medical director of the laboratory was assigned an Ontario Health Insurance Plan identification number on or after January 1, 1993 and before January 1, 2003.

(4) Subsections (2) and (3) do not apply to a claim for the cost of an insured service rendered by a dental surgeon.

(5) A processing fee is payable under the regulations under the Interpretation Act for  every claim received after July 13, 1993, unless the claim is submitted by electronic data transfer or in a machine readable form acceptable to the Ministry of Health and Long-Term Care.

(6) This section does not apply to a claim for a service rendered to an insured person outside of Ontario.

38.4 (1) It is a condition of payment of a claim for an insured service rendered to an insured person in Ontario that the claim include the following information:

1. The Ontario Health Insurance Plan identification number for,

i. the physician or practitioner who rendered the service,

ii. the physiotherapy facility listed in Schedule 5 to this Regulation that  rendered the service, or

iii. the medical director of the laboratory in which the service was rendered.

2. If the service was rendered by a physician, practitioner or laboratory,

i. the four characters assigned by the Plan that indicate whether the physician or practitioner practices alone or with one or more other physicians or practitioners or whether the service was provided in a laboratory, and

ii. the two characters assigned by the Plan that indicate the specialty of the physician, if any, or the specialty or profession of the practitioner or laboratory director, if any.

3. The most recently issued 10 digit health number for the insured person to whom the service was provided and any version code that may appear on the person’s health card bearing that number.

4. The date of birth of the insured person to whom the service was rendered.

5. The payment program code “HCP”.

6. Any characters assigned by the Ministry of Health and Long-Term Care that identify the payee as a provider or recipient of the insured service.

7. If the service is a diagnostic radiology procedure in accordance with the schedule of benefits, the Ontario Health Insurance Plan identification number of the referring physician or registered nurse in the extended class.

8. If the service is a laboratory or other diagnostic procedure listed under “Nuclear Medicine”, “Pulmonary Function Studies” or “Diagnostic Ultrasound” in the schedule of benefits, the Ontario Health Insurance Plan identification number of the referring physician, midwife, registered nurse in the extended class or laboratory.

9. If the service is a consultation in accordance with the schedule of benefits, the Ontario Health Insurance Plan identification number of the referring physician.

10. If the service is an assessment requested by a midwife in accordance with the schedule of benefits, the Ontario Health Insurance Plan identification number of the midwife.

11. If the service was rendered in a mobile independent health facility licensed under the Independent Health Facilities Act or if the service consists of the interpretation of the results of a diagnostic procedure performed in that type of facility, the four character service site indicator assigned by the Plan to identify the location at which the service was rendered.

12. If the service was provided to a person who was an in-patient in a hospital, the date of the person’s admission to the hospital.

13. If the service was rendered by a physician who was issued an Ontario Health Insurance Plan identification number after December 16, 1996, the numeric code assigned by the Ministry of Health and Long-Term Care for the location where the service was rendered.

14. The fee code that, in the circumstances in which the service was rendered, correctly describes the service as specified,

i. in the schedule of benefits, if the service was rendered by a physician,

ii. in Schedule 13, 14 or 15 to this Regulation, if the service was rendered by a member of the Royal College of Dental Surgeons of Ontario,

iii. in Schedule 23 to this Regulation, if the service was rendered by a member of the College of Optometrists of Ontario, and

iv. by the Plan, if the service was rendered by a podiatrist who is a member of the College of Chiropodists of Ontario, by a member of the College of Chiropractors of Ontario, by an osteopath or by a member of the College of Physiotherapists of Ontario in a physiotherapy facility listed in Schedule 5 to this Regulation.

15. In the case of a service other than a laboratory service described in section 22, the amount of the fee being claimed.

16. If it is relevant under the schedule of benefits, the number of times the service was rendered or the number of units claimed for the service.

17. The date the service was rendered.

18. If it is required by the Plan, the diagnostic code specified by the Plan for the service that relates to the insured person’s condition.

19. If the service was an X-ray or laboratory or other diagnostic procedure that was provided in a hospital upon the requisition of an oral and maxillofacial surgeon, the Ontario Health Insurance Plan identification number of the referring oral and maxillofacial surgeon.

(2) It is a condition of payment of a claim for an insured service rendered in Ontario to a person who is insured by a health insurance scheme provided by another province or territory of Canada applies that the following information be included:

1. The payment program code “RMB”, the health number or other identification number issued to the person by the health insurance scheme in the other province or territory, the person’s first and last names, the person’s sex and the code for the province or territory in which the person is insured, as specified by the Plan.

2. The Ontario Health Insurance Plan identification number for,

i. the physician who rendered the service, or

ii. the medical director of the laboratory in which the service was rendered.

3. If the service was rendered by a physician or laboratory,

i. the four characters assigned by the Plan that indicate whether the physician practices alone or with one or more other physicians or whether the service was provided in a laboratory, and

ii. the two characters assigned by the Plan that indicate the specialty of the physician, if any, or the specialty of the laboratory director, if any.

4. Any characters assigned by the Ministry of Health and Long-Term Care that identify the payee as a provider or recipient of the insured service.

5. If the service is a diagnostic radiology procedure in accordance with the schedule of benefits, the Ontario Health Insurance Plan identification number of the referring physician.

6. If the service is a laboratory or other diagnostic procedure listed under “Nuclear Medicine”, “Pulmonary Function Studies” or “Diagnostic Ultrasound” in the schedule of benefits, the Ontario Health Insurance Plan identification number of the referring physician.

7. If the service is a consultation in accordance with the schedule of benefits, the Ontario Health Insurance Plan identification number of the referring physician.

8. If the service was rendered in a mobile independent health facility licensed under the Independent Health Facilities Act or the service consists of the interpretation of the result of a diagnostic procedure preformed in that type of facility, the four character service site indicator assigned by the Plan to identify the location at which the service was rendered.

9. If the service was provided to a person who was an in-patient in a hospital, the date of the person’s admission to the hospital.

10. If the service was rendered by a physician, the fee code that, in the circumstances in which the service was rendered, correctly describes the service as specified in the schedule of benefits. 

11. In the case of a service other than a laboratory service described in section 22, the amount of the fee being claimed.

12. If it is relevant under the schedule of benefits, the number of times the service was rendered or the number of units claimed for the service.

13. The date the service was rendered.

14. If it is required by the Plan, the diagnostic code specified by the Plan for the services that relates to the insured person’s condition.

(3) In the case of a claim submitted in machine readable form, it is a condition of payment that the claim include the following additional information with respect to each service for which payment is claimed:

1. The transaction identifier code “HE”.

2. The appropriate identification code for the record.

3. The identifier code for the technical specification release.

4. The code for the Ministry of Health and Long-Term Care district office where the service provider is registered for the purpose of claims payments.

5. In the case of a claim that is included in a batch of claims, the date on which the batch of claims was created and the sequence number of the batch.

6. The operator number assigned by the Ministry of Health and Long-Term Care to the person authorized to submit the claim by magnetic cartridge or tape.

7. On the last record in each batch of claims, the total number of each of the record identification codes H, R, and T.

38.5 In sections 38.3 and 38.4,

“Ontario Health Insurance Plan identification number” means the number issued by the Plan to a physician, practitioner, registered nurse in the extended class, midwife, medical director of a laboratory licensed under the Laboratory and Specimen Collection Centre Licensing Act, hospital or health facility for the purposes of monitoring, processing and paying claims for payment of insured services and of monitoring and controlling the delivery of insured services.

2. This Regulation comes into force on January 1, 2003.