In CabMD, we've integrated the schedule of benefits as complete as possible but it will never be complete due to it's complexity. In the beginning, we sat down and determined all the services and rules that were described in the documentation but quickly found out that it's a) not that simple and b) terribly terribly documented. We've tried for years to get a concise listing of the billing rules from the MOHLTC but have been unsuccessful as they deem that to be a security issue. If people knew the rules completely, then they could defraud the system or take advantage of little known methods.

Regardless, the system we've built incorporates all the rules we've found, the rules we've determined as given by our users and the rules as part of integrating with major hospital systems. We're fairly confident in the logic though we're always open to make adjustments because it's an ever changing system and there's no 100% documentation publicly available.

Service Codes vs Premiums Codes

Technically all OHIP services are "fee service codes" but we distinguish them into the categories "services" and "premiums":

  • Service - Any service that can generally be billed alone or in-conjunction with other services (like procedures and consultations). Generally all codes start with a letter prefix, followed by three numbers and a letter suffix like PXXXS where P is the prefix letter followed by XXX (three digits) followed by the S suffix letter (A, B or C). A consult might be "A001A". E-prefix codes are generally premiums. As with everything with the Ministry, there are exceptions to this.
  • Premium - Any service that must generally be billed in conjunction with a service (can't be billed alone) or services that modify/add-on the service. Premiums generally start with E-prefix but can also be others (A, B, C, K, T, etc). The largest block of premiums all begin with E (E078A - Chronic Disease Premium, E082A - Most Responsible Physician Premium, etc).

What do I do when I can't find the service I'm looking for?

Generally we only allow users to see the services that apply to their specialty codes so if you are looking for services that can't be seen, then it's likely you're missing specialty codes that apply to you.

What do I do when I can't find the premium I'm looking for?

It's generally one of two things, either the premium doesn't apply in the claim scenario or the premium isn't yet associated with the services/scenario you're using. We can attempt to find the reason it might not apply, but calling the MOHLTC Claims Services branch is also an option. If you're convinced it should be, let us know and we can start that process of adding it (testing a claim, seeing if it's paid as expected).

How do I enter a service code?

When adding a claim, you simply type the service into the service code field and select it by either clicking or hitting tab/enter.

How do I enter a premium code?

  • When entering a new claim, the applicable premiums are shown when you go to save the claim.
  • When editing an existing claim, you can edit or select the applicable premiums by clicking on the "Premium(s)" field. If you hover over the field, it will also tell you that you can click it to edit. The reason these are different is that editing claims is very common and it would be very annoying for users to have to ignore the premium window when they are just doing simple tasks like changing dates or version codes every single time.
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