In Canada, we are fortunate to have government funded health care. Medicare is the ever-changing, publicly funded system that continues to evolve to changes within medicine and the society to meet medically necessary health care services. However, instead of having a single health care plan for all across Canada, there are 13 provincial and territorial health care insurance plans unique to their residents. This article will walk you through OHIP billing, the process by which optometrists in Ontario bill and claim their services under Ontario's unique insurance plan.
For those interested in starting their optometry career in Canada, please refer to each province's health service guidelines for more information on the coverage plans and how to register as an eyecare provider. In this article, I will primarily focus on how optometrists register to Ontario bill and submit claims for Ontario government insured plans, known as Ontario Health Insurance Plan (OHIP) for 2018.
Make sure to refer to the documents and OHIP guides linked in each section!
Step 1: Registering for Ontario Health Insurance Plan (OHIP) billing number and verification
Once a Certificate of Registration is issued and membership is activated with the College of Optometrists of Ontario, you may then apply for an Ontario Health Insurance Plan (OHIP) billing number. Make sure you have the billing number application details correct! This number is different from your optometry license number. In order for eye care professionals and other health providers to submit claims for OHIP insured services to the Ministry of Health and Long-Term Care, every provider must apply and register for a billing number. In the registration, your banking information can be provided to support direct payment from the government.
You will also be submitting claims electronically for the exam services you provided, so registering for the Medical Claims Electronic Data Transfer (MCEDT) is required. In order to validate an individual's eligibility for their eye exam coverage, you must also register for Health Card Validation (HCV) services.
You’ll utilize this feature every time you see an OHIP patient. It provides you access to the Ministry's database to know whether the individual is eligible for the eye exam, when the last service date was, whether the health card is still valid, etc. For example, if the health card is expired or if the patient's last eye exam was less than a year ago, the call system will prompt you with an error code indicating that the patient is not eligible for OHIP services. In this situation, either the patient must renew their expired health card or wait until the eligible service date for the eye care. Otherwise, the patient can pay out of their own pocket for the eye exam.
Make sure to familiarize yourself with the validation process and OHIP service eligibility. Regardless of where you practice and whether you see a high prevalence of OHIP insured patients or very few, you should always register for an OHIP billing number as long as you are a practicing provider in Ontario.
Step 2: Know your OHIP patients and exam services
The best way to train yourself and your staff to avoid the chances of OHIP claim rejections is to be familiar with the OHIP codes. Based on age alone, you should know that any patient who walks through your door that is 19 years and younger or 65 years and older may be eligible for OHIP services as long as their last full eye exam was more than a year ago. Remember to check their health card for validity and eligibility as mentioned in the previous links above.
Individuals ages 20-64 may also be covered once a year if they have any of the specified medical conditions such as diabetes mellitus, glaucoma, cataract, retinal disease, amblyopia, visual field defects, corneal disease, strabismus, recurrent uveitis, optic pathway disease, or others.
For the insured annual coverage, it is required that you provide a complete eye examination that will assess the visual acuity, ocular motility, refraction and written prescription if necessary, slit lamp evaluation of the anterior segment, fundus exam, and if required tonometry, visual field testing, and dilation. Only visual field testing can be a billed service under OHIP but any additional services like taking pachymetry or tonometry cannot be claimed (as it was considered part of the standard eye exam procedure).
The billing code for 19 years old and younger is V404, 20-64 years old with medical condition is V409, and 65 years and older is V406.
The follow-up visit or minor assessment for the same particular condition is billed V402 for 19 years and younger or 65 years and older or billed V408 for 20-64 years old. It is important to know that the claim will be rejected if the follow-up visit is billed for a different condition than the initial diagnosis first claimed in their full eye exam. The claim would also render a payment of zero if this follow-up service code was submitted on the same day as the full exam service date or if it was billed twice on the same day.
For example, a V409 exam service for a patient that had been seen for their glaucoma for their initial encounter at the eye exam cannot be billed V408 with a diagnosis of corneal ulcer for their next follow-up visit. It would likely be rejected. You must make sure the initial diagnosis code is billed as the primary reason for their visit is submitted instead to reduce chances of zero payment.
Step 3: Know your diagnostic codes
In order to submit each billing service electronically, it must include a diagnostic code for the primary condition. Common conditions of the lid, refractive error, corneal issues, and others are listed with their corresponding diagnostic code. All disorders of the eyes will be covered as government insured services as long as the patient is eligible under the claim for V404, V406, and V402 OHIP.
For example, when a child is coming for a routine eye exam and has myopia, you would most likely bill as V404 367 (V404 since patient presents for first full eye exam and is under 19 years old , while 367 is the diagnostic code for refractive error caused by myopia, astigmatism, hyperopia, or presbyopia).
As mentioned previously, subsequent visits within the same year (billed as V402) should refer to the initial problem assessed in the first exam when it was billed as V404 and V406.
Other medical conditions that can only be billed in combination with the service code V409 or V408 are specific for glaucoma, diabetes, cataract, amblyopia, and others listed beforehand.
Step 4: Submitting your claim and receiving payment for OHIP services
Claims that are submitted properly will be processed every month on a billing cycle. These submissions should have complete information (accurate health card number, version code, date of birth, and service date and diagnostic code), and will be reviewed by the ministry staff when received electronically. Claims that are processed by the 18th of the month will typically be paid out by the 15th of the next month into the direct banking institution of the optometrist. The ministry always recommends that claims are submitted in a timely manner to ensure payment is received for the billing cycle. When claims are rejected or not submitted, there will be time to resubmit again even after the service date has passed. You have up to 6 months to claim again for the service provided.
By following these basic instructions, hopefully it will make the submitting and claiming process easier to understand for new optometrists that will be practicing in Ontario.