O. Reg. 5/04: GENERAL

 

ontario regulation 5/04

made under the

health insurance act

Made: February 4, 2004
Filed: February 9, 2004
Printed in The Ontario Gazette: February 28, 2004

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

(General)

1. Subsection 38.2.2 (5) of Regulation 552 of the Revised Regulations of Ontario, 1990 is revoked and the following substituted:

(5) For the purposes of subsections (1), (2) and (3), if the direction of the committee is made on or after April 1, 2003 and if the circumstances set out in subsection (5.2) do not apply, the number of review days in a review or reconsideration is the lesser of 15 and the number determined as follows:

1. For each member of the committee, determine the number of days, including any partial days rounded to the first decimal, the member spent working on the review or reconsideration and on related matters after commencing to hear from the physician or practitioner.

2. If the parties agreed to a settlement of the review or reconsideration, determine, for each member, the number of days, including any partial days rounded to the first decimal, the member spent considering and agreeing to the offer to settle after commencing to hear from the physician or practitioner.

3. For each member of the committee, determine the days that are spent by the committee in hearing from the physician or practitioner, including any partial days rounded to the first decimal, to a maximum of two days.

4. For each member, subtract the number of days determined for the member under paragraphs 2 and 3 from the number of days determined for the member under paragraph 1.

5. Add the numbers determined under paragraph 4 for each member to calculate the total number of days all the members of the committee spent working on the review or reconsideration and on related matters. 

6. For the purposes of the calculations in paragraphs 1, 2 and 3, the committee is “hearing from the physician or practitioner” when the physician or practitioner or his or her counsel or agent is in the presence of the committee for the purpose of making representations.

(5.1) For the purposes of subsections (1), (2) and (3), if the direction of the committee was made before April 1, 2003 or if the circumstances set out in subsection (5.2) apply, the number of review days in a review or reconsideration shall be determined as follows:

1. For each member of the committee, determine the number of days, including any partial days rounded to the first decimal, the member spent working on the review or reconsideration and on related matters.

2. If the parties agreed to a settlement of the review or reconsideration, determine, for each member, the number of days, including any partial days rounded to the first decimal, the member spent considering and agreeing to the offer to settle.

3. For each member, subtract the number of days determined for the member under paragraph 2 from the number of days determined for the member under paragraph 1.

4. Add the numbers determined under paragraph 3 for each member to calculate the total number of days all the members of the committee spent working on the review or reconsideration and on related matters. 

(5.2) The following are set out as circumstances for the purposes of subsections (5) and (5.1):

1. In the case of a practitioner, if a direction under subsection 18.1 (10) of the Act has previously been made requiring the practitioner to reimburse money to the Plan or directing the General Manager to pay an amount to the practitioner that is less than the amount of the account submitted.

2. In the case of a physician,

i. if a direction under subsection 18.1 (10) of the Act has previously been made requiring the physician to reimburse money to the Plan or directing the General Manager to pay an amount to the physician that is less than the amount of the account submitted, and

ii. the direction related, in whole or in part, to a claim or claims submitted with regard to one or more of the same schedule of benefits fee codes or classes of fee code as the claim or claims giving rise to the current review or reconsideration.

(5.3) The following are classes of fee code for the purposes of paragraph 2 of subsection (5.2):

1. Class 1 — all codes which are in respect of diagnostic tests or services, or the interpretation of a diagnostic test or service.

2. Class 2 — all codes in respect of surgical services.

3. Class 3 — all codes in respect of anesthesia services.

4. Class 4 — all codes other than those contained in any of classes 1 to 3.

2. This Regulation shall be deemed to have come into force on April 1, 2003.