Out-of-Province Referral – What Can a Physician bill?
- 2 min read
In Ontario, the process of billing for physician services involves strict adherence to guidelines set by the Ontario Health Insurance Plan (OHIP). For physicians, particularly those dealing with out-of-province (OOP) referrals, it is vital to understand how these regulations affect consultation claims.
One key requirement for billing consultations under OHIP is the inclusion of the referring physician’s OHIP identification number. This is outlined in section 38.4 of Regulation 552. Additionally, the Schedule of Benefits for Physician Services specifies that a valid consultation request must be in writing and include both the referring physician or nurse practitioner’s name and their OHIP billing number. Unfortunately, since OOP physicians do not have an OHIP billing number, claims for consultations initiated by them are not eligible for payment.
An out-of-province referral occurs when a patient is relocating to Ontario and is referred for ongoing care. It may also occur when specialized treatment of a condition may not otherwise be available in their home Province.
Instead of billing for a consultation, the physician can claim an alternative assessment based on their specialty including:
- Specific Assessment
- Medical Specific Assessment
- General Assessment
By claiming the appropriate assessment, physicians can still provide and bill for valuable services to patients referred by OOP physicians, ensuring compliance with OHIP’s regulations.
Should you have any further questions on billing, our billing experts are always available to help you out with your billing needs!
Please feel free to reach out to your Billing Advisor representative. They can help you with any further questions or provide assistance.
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