OHIP Technical Specification

Technical
Specifications
Interface to Health Care Systems
Technical Specifications Interface to Health Care Systems
All possible measures are exerted to ensure accuracy of the contents of this manual; however,
the manual may contain typographical or printing errors. The public is cautioned against
complete reliance upon the contents hereof without confirming the accuracy and currency of
the information contained herein. The Crown in Right of Ontario, as represented by the Minister
of Health and Long-Term Care, assumes no responsibility for any persons use of the material
herein or any costs or damages associated with such use.
Ministry of Health and Long-Term Care

Registration and Claims Branch
Current as of September 2007
(i)
Table of Contents
Table of Contents
1.
Introduction
1.1
1.2
2.
General Information
2.1
2.2
2.3
3.
Media Types .........................................................................................................................4 - 1
Machine Readable Input Specifications

5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
5.10
5.11
5.12
5.13
5.14
5.15
5.16
6.
Initial Claims File.................................................................................................................3 - 1

Patient Set-Up File ...............................................................................................................3 - 2
Media Specifications
4.1
5.
Processing Schedules ...........................................................................................................2 - 1

Shipping Requirements ........................................................................................................2 - 1
Labels ...................................................................................................................................2 - 2
Claims Submission
3.1
3.2
4.
Introduction ..........................................................................................................................1 - 1
Office Locations and Contact Numbers ...............................................................................1 - 2
File Naming convention .......................................................................................................5 - 1

Submission from Health Care Providers ..............................................................................5 - 1
Format Summary..................................................................................................................5 - 2
Batch File Submission Sample.............................................................................................5 - 3
Summary of Data Requirements ..........................................................................................5 - 4
MRI Record Layout..............................................................................................................5 - 5
Specialty Codes ..................................................................................................................5 - 15
Services Requiring Diagnostic Codes ................................................................................5 - 17
Fee Schedule Code Relationships ......................................................................................5 - 19
Fee Schedule Code Suffix B/C Exceptions ........................................................................5 - 26
Service Codes .....................................................................................................................5 - 27
Service Location Indicator Codes ......................................................................................5 - 28
MOD 10 Check Digit .........................................................................................................5 - 35
Province Codes and Numbering.........................................................................................5 - 36
Valid Payment Program/Payee Combination .....................................................................5 - 37
Workforce Safety and Insurance Board .............................................................................5 - 38
Machine Readable Output Specifications

6.1
6.2
6.3
6.4
6.5
6.6
6.7
Remittance Advice ...............................................................................................................6 - 1

Remittance Advice Data Sequences.....................................................................................6 - 1
File Naming Convention ......................................................................................................6 - 3
Format Summary..................................................................................................................6 - 4
MRO Record Layouts ..........................................................................................................6 - 6
Accounting Transactions for Record Type 7......................................................................6 - 18
Remittance Advice Explanatory Codes..............................................................................6 - 19
( ii )
Table of Contents
Table of Contents
7.
Rejection Conditions
7.1
7.2
7.3
7.4
8.
Health Card Magnetic Stripe Specifications

8.1
8.2
9.
Correction of Errors..............................................................................................................7 - 1
Rejection Categories.............................................................................................................7 - 1
Error Report Explanatory Codes ........................................................................................7 - 20
Error Report Rejection conditions......................................................................................7 - 21
Health Card Types................................................................................................................8 - 1
Magnetic Stripe Specifications.............................................................................................8 - 2
Overnight Batch Eligibility Checking (OBEC)

9.1
Overview ..............................................................................................................................9 - 1
10. Health Card Validation

10.1
11.
Overview...........................................................................................................................10 - 1
Glossary
11.1
11.2
Glossary ............................................................................................................................11 - 1
Websites............................................................................................................................11 - 8
( iii )
1. INTRODUCTION
1.1
Introduction........................................................................................................ 1 - 1
1.2
Office Locations and Contact Numbers..............................................................1 - 2
Introduction
1. Introduction
1.1 Introduction
This manual is provided for developers of computer systems used by health care providers.
This manual specifies the content and format of the information exchanged with the Ministry of
Health and Long-Term Care (ministry) and the operational procedures to be followed.
The technical specifications contained in this text are subject to change by the ministry. The
ministry will attempt to provide 60 days notice of any change.
Any questions or concerns regarding the content of this manual should be directed to your local
ministry office (refer to Section 1.2 Office Locations and Contact Numbers).
1-1
Introduction
1.2 Office Locations and Contact Numbers

MRI/MRO
Claim Cards
Offices
Hamilton
119 King Street West, 10th Floor

Hamilton ON L8P 4Y7
Phone: (905) 521-7547
Fax:
(905) 521-7605
Kingston
1055 Princess Street, Ste. 401

Kingston ON K7L 5T3
Phone: (613) 545-4305
Fax:
(613) 545-4399
London
217 York Street, 5th Floor

London ON N6A 5P9
Phone: (519) 675-6800
Fax:
(519) 675-6832
Mississauga
201 City Centre Drive, Ste. 300

Mississauga ON L5B 2T4
Phone: (905) 896-6000
Fax:
(905) 896-6025
Oshawa
419 King Street West

Oshawa ON L1J 7J2
Phone: (905) 434-3709
Fax:
(905) 434-4186
Ottawa
75 Albert Street, 7th Floor

Ottawa ON K1P 5Y9
Phone: (613) 783-4412/783-4411
Fax:
(613) 237-3246
Sudbury
199 Larch Street, Ste. 801

Sudbury ON P3E 5R1
Phone: (705) 675-4055/675-4056
1 800 461-4006
Fax:
(from area 705)
(705) 675-4015
Thunder
Bay
435 James Street South, Ste 113

Thunder Bay ON P7E 6T1
Phone: (807) 475-1423
1 800 461-4006
Fax:
(from area 705)
(807) 475-1424
Toronto
47 Sheppard Ave. East, Ste. 417

Toronto ON M2N 7E7
Phone: (416) 314-7498/314-7499
Fax:
(416) 314-7487
1-2
2. GENERAL INFORMATION
2.1
2.2
2.3
Processing Schedules ......................................................................................... 2 - 1

Shipping Requirements...................................................................................... 2 - 1
Labels................................................................................................................. 2 - 2
General Information
2. General Information
2.1 Processing Schedules
Claims should be submitted evenly, for example, daily or weekly throughout the month to
facilitate smooth processing and timely correction of errors.
Diskettes/Tapes
The cut-off date for claims submitted on diskette is the 18th of the month. When the 18th falls on
a weekend or a holiday, the cut-off date will be extended to the following business day.
Error reports will be mailed within approximately one week of receipt of the submission.
Remittance Advices are created during month-end.
Electronic Data Transfer (EDT)
The cut-off date for claims submitted via EDT is the 18th of the month; however, claims
submitted via EDT after the 18th of the month may be processed until the month-end mainframe
cut-off date, where time and volume permits.
Error reports will be sent in approximately 48 hours after receipt of the submission.
Remittance Advices are created during month-end and will have a file subject of Remittance
Advice.
2.2 Shipping Requirements

The health care provider is responsible for transporting diskettes or tape cartridges to
the ministry offices. Diskettes must be placed in a mailer/envelope as prescribed by the ministry.
Tape cartridges must be securely packaged and may be either mailed or delivered. Diskettes or
tape cartridges submitted to the ministry must have an affixed identification label.
Processed diskettes will be reformatted or modified before being returned to the health care
provider. Tapes and tape cartridges will be returned intact.
For health care providers who choose 3.5" diskettes, the ministry will supply diskettes in the
approved media format. The ministry provides 3.5" (1.44MB/1.40 MB) diskettes for use in
production.
Remittance advice(s) on diskettes are identified with yellow labels. Remittance advice(s) on
cartridge are identified with a yellow six-digit Volume Serial Number. All media types remain
the property of the ministry and must be returned promptly to the appropriate ministry office
upon completion of the monthly reconciliation.
2-1
General Information
2.3 Labels
Multi-volume remittance advice diskettes are externally labeled (e.g., 1 of 3, 2 of 3) to identify
the sequence in which the volumes were created and should be read. For multi-volume
remittance advice magnetic tapes, the sequence of the volumes is identified by an accompanying
report. The total number of records in the file appears on the external label (diskette) or on the
accompanying report (cartridge).
3490 Tape Cartridge Labels
Name of the Health Care Provider, Group or Billing Agent
Number of records submitted incorrect record counts will result in rejection of

these media
Creation date
Serial number (originators identification: 3 alphabetics assigned by the ministry,

followed by three numerics) this number must also be present on the tape flange
Name:
# of Records:
Creation Date:
Serial #:
ABC Laboratories
20,000
Jan. 02, 1991
ABC123
2-2

2.3
General Information
Labels (continued)
3.5" Diskette Labels
Health Care Provider or Group Name
Diskette Identification - name of the MS-DOS or Macintosh file that appears on

the diskette, for example, HA123456.001 (refer to the File Naming Conventions)
Phone number of contact person (in case of file/batch rejection)
Number of claims submitted
Number of records submitted
Date of submission to the ministry

Sequence number (e.g., 1 of 3, 2 of 3, 3 of 3) if it is a multi-volume diskette submission
MOHLTC OTTAWA
2-3
3. CLAIMS SUBMISSION
3.1
Initial Claims File .............................................................................................. 3 - 1
3.2
Patient Set-Up File............................................................................................. 3 - 2
Claims Submission
3. Claims Submission
3.1 Initial Claims File
New health care providers/billing agents and providers who are transitioning from submitting
their claims by paper to an electronic method can begin submitting claims to the ministry in a
live (production) environment once they are successfully registered for electronic claims
submission.
The health care provider/billing agent must submit claims data that conforms to the
specifications in this manual and to the general requirements for information exchange with the
ministry.
Health care providers/billing agents are encouraged to work closely with their local district
claims processing office following submission of their initial claims file. They must be aware of
the importance of viewing their error reports and notifying the ministry immediately if problems
or errors are detected.
For further information on registering for electronic claims submission refer to the Electronic
Data Transfer Reference Manual.
Reference:
Schedule of Benefits
http://www.health.gov.on.ca/english/providers/program/ohip/sob/physserv/physserv_mn.html
or order at: http://www.publications.gov.on.ca
Resource Manual for Physicians
http:www.health.gov.on.ca/english/providers/pub/ohip/physmanual/physmanual_mn.html
Service codes requiring diagnostic codes, prior authorization or supporting documentation are
located in Section 5.8 Services Requiring Diagnostic Codes and Section 5.11 Service Codes.
3-1
Acceptance Testing
3.2 Patient Set-Up File

The Patient Set-up File is a ministry initiative intended to assist health care providers in their
transition from paper claims submission to machine readable input submission. Upon request,
the ministry will supply a Set-up File diskette to providers containing basic patient biographic
information. The file consists of patient data for whom a claim has been submitted and approved
in the past six months.
The Patient Set-up File is an optional feature and is available in MacIntosh and IBM-compatible
(MS/DOS) formats. Medical billing software vendors may choose to develop a facility to load
the Set-up File contents into the computers patient database.
Header Record Patient Set-Up File

Field Name
Field
Start
Position
Field
Length
Format
Record Type
Group Number
Provider Number
Requesting Office
12
Request Date
13
Number of Records
21
Reserved for MOH

Use
28
56
3-2
Field Description
1=Header
YYYYMMDD
Must be spaces
3.2
Acceptance Testing
Patient Set-Up File (continued)
Detail Record Patient Set-Up File

Field Name
Field
Start
Position
Field
Length
Format
Record Type
Patient Surname
30
Patient First Name
32
20
Patient Initial(s)
52
Health Number
54
10
Version Code
64
Version Code Match
66
Patient Birth Date
67
Patient Sex
Last Service Date
Field Description
2 = detail
Y = yes N = no (refer to Note)
YYYYMMDD
75
1 = Male 2 = Female
76
YYYYMMDD
NOTE:
The Patient Set-up File identifies the

version code submitted with the last
approved claim.
Y in the version code match field
indicates that the version code
present in the ministry computer
systems matches the version code in
the Patient Set-up File.
N in the version code match field
indicates a mismatch.
3-3
4. MEDIA SPECIFICATIONS
4.1
Media Types....................................................................................................... 4 - 1
4. Media Specifications
4.1 Media Types
EDT
ASCII Data Content
Logical Record Length = 79 characters

Modem
Telephone or analogue line
Dial-up communication software
3.5" Diskette
ASCII Data Content
Soft Sectored Only

Apply MacIntosh format 1.40 MB or MS-DOS format 1.44MB
Logical Record Length 79 characters
3490 Cartridge
Standard Label
36 Track
38KC (compacted)
IBM EBCDIC
Maximum Blocking Factor = 414 (block size 32706)

Logical Record Length = 79 characters
Maximum Number of Records = 200,000
4-1
Media Specifications
5. MACHINE READABLE INPUT (MRI)

SPECIFICATIONS
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
5.10
5.11
5.12
5.13
5.14
5.15
5.16
File Naming Convention.................................................................................... 5 - 1

Submission from Health Care Providers............................................................ 5 - 1
Format Summary ............................................................................................... 5 - 2
Batch File Submission Sample .......................................................................... 5 - 3
Summary of Data Requirements........................................................................ 5 - 4
MRI Record Layout ........................................................................................... 5 - 5
Specialty Codes................................................................................................ 5 - 15
Services Requiring Diagnostic Codes.............................................................. 5 - 17
Fee Schedule Code Relationships.................................................................... 5 - 19
Fee Schedule Code Suffix B/C Exceptions .....................................................5 26
Service Codes...................................................................................................5 27
Service Location Indicator Codes....................................................................5 28
MOD 10 Check Digit.......................................................................................5 35
Province Codes and Numbering ......................................................................5 36
Valid Payment Program/Payee Combination ..................................................5 37
Workplace Safety and Insurance Board...........................................................5 38
5. Machine Readable Input (MRI) Specifications

5.1 File Naming Convention
The Input Submission must have file names in the following format:
H
Month
Example:
Field 1
Field 2
Field 3
Field 4
Group Number or Provider Number
Sequence Number
HA123456.001 or HA1234.001
H represents the claims input billing
Alpha representation for current processing cycle

(e.g., A for January, B for February)
Health care providers registered group number
or solo health care provider number
Three digit sequence number assigned by
the health care provider
Each input file must have a Batch Trailer Record at the end of the file(s). The file names must
have a unique sequence number when there is more than one file per submission.
For EDT/DOS/MacIntosh diskettes, there must be a carriage return (hex value 0D) and a line feed
indicator (hex value OA) at the end of each record. The end of the file must be indicated by a
CTRL Z (hex value of 1A). If a file requires more than one diskette, the end of each diskette is
also indicated by CTRL A.
3490 Tape Cartridges
3490 tape cartridges must use standard labels with file name HESK.MCON.CARTRDGE
NOTE: For this media, multiple files are not permitted.
5.2 Submission from Health Care Providers

Submissions include:
In-province medical claims detailed in the Schedule of Benefits, including services that
require additional information or prior authorization (HCP)
Reciprocal Medical Billing claims (RMB)
Workplace Safety and Insurance Board claims (referred to as WCB claims)
These categories are identified as Payment Programs HCP, RMB, and WCB respectively. Other
types of submissions may be included in the MRI/MRO system in the future (refer to Section
5.15 Valid Payment Program/Payee Combinations).
5-1
5.3 Format Summary

Record Type
B
Description
Batch Header Record
The first record of each batch must be a Batch Header Record. In multiple
batch submissions, the first record of each subsequent batch must always
be a Batch Header Record.
Claim Header-l Record

A Claim Header-l Record must always follow each Batch Header Record
and must always be present for each claim.
Claim Header-2 Record

A Claim Header -2 Record is required only for reciprocal claims. If required,
a Claim Header-2 Record must follow the Claim Header-l Record.
Item Record
An option of having two items per Item Record has been provided and
may be utilized.
Batch Trailer Record

A Batch Trailer Record must be present at the end of every batch and contain
the appropriate counts of the number of Claim Header-l Records (H), Claim
Header-2 Records (R) and Item Records (T).
5-2
5.4 Batch File Submission Sample
HEE
BATCH TRAILER
HET
ITEM
HET
RMB
HER
HEH
HEALTH
NUMBER
CLAIM
HET
CLAIM HEADER-2
CLAIM HEADER-1
ITEM
HEH
HEB
ITEM
CLAIM HEADER-1
BATCH HEADER
Fixed Record Length: 79 Characters
5-3
5.5 Summary of Data Requirements

Payment Program
Record
Field
HCP / WCB
M
RMB
M
Health Number
Version Code
Patient Birthdate
Accounting Number
Payment Program
Payee
Ref./Req. Provider No.
Master Number
In-Pat. Admission Date
Ref.Laboratory No.
Manual Review Indicator
Service Location Indicator *
M
M
M
O
M
M
C
C
C
C
C
C
N/R
N/R
M
O
M
M
C
C
C
C
C
C
N/R
N/R
N/R
N/R
N/R
N/R
M
M
M
M
M
M
M
M
M
C
M
M
M
M
C
Claim Header-1
Claim Header-2
Registration Number
Patient Last Name
Patient First Name
Patient Sex
Province Code
Item
Service Code
Fee Submitted
Number of Services
Service Date
Diagnostic Code
M = Mandatory
O = Optional
C = Conditional
* Effective April 1, 2006
5-4
N/R = Not Required
5.6 MRI Record Layout

Health Encounter
Format Legend
A = Alphabetic
N = Numeric
X = Alphanumeric
D = Date (YYYYMMDD)
S = Spaces
Notes
If a field is Not Required it should be spaces unless
otherwise indicated.
All alphabetic characters must be upper-case.
The last 2 digits of all the amount fields are cents ().
5-5
5.6
MRI Record Layout (continued)
Batch Header Record Health Encounter

First Record of Every Batch
Field Name
Field
Start
Position
Field
Length
Format
Field Description
Transaction Identifier
Must be HE
Record Identification
Must be B
Tech Spec Release

Identifier
Must be V03
MOH Office Code
Must be a valid code for MRI

determined by the MOHLTC
office in which the Health Care
Provider/Group is registered
(refer to Section 1.2 Office
Locations and Contact Numbers)
Batch Identification
12
Must be in format
YYYYMMDD####
Operator Number
20
N or S
First 8 digits are the Creation

Date (the date the input file is
created)
Last 4 digits are a sequential
number assigned by the Health
Care Provider/Billing Agent
Service Date on the Item
Records cannot be greater than
the Creation Date
For Magnetic Tape and Cartridge
Submissions only
Must be the Operator Number
assigned by the ministry for that
Group or Health Care Provider
Right justified with leading zeros
Zero fill or space fill for 3.5
diskettes
continued . . .
5-6
5.6
Batch Header Record Health Encounter

First Record of Every Batch
Field Name
Field
Start
Position
Field
Length
Format
Field Description
Group Number or
Laboratory Licence
Number or
Independent Health
Facility Number
26
Health Care Provider/

Private Physio
Facility/ Laboratory
Director/ Independent
Health Facility
Practitioner Number
30
Must be present
Must be a ministry assigned
registration number for the
Health Care Provider
Specialty
36
Must be a valid specialty code

assigned by the ministry (Refer
to Section 5.7 Specialty Codes)
Reserved for MOH

Use
38
42
Must be spaces
Must be present
Must be a group number
registered with the ministry
Must be 0000 (zeros) for a solo
Health Care Provider/Private
Physiotherapy Facility
NOTE:
All claims in a batch must be for

the same Health Care Provider.
The first record in a batch must be
a Batch Header Record. A Batch
Header Record must always be
followed by a Claim Header-1
Record.
5-7
5.6
Claim Header 1 Record Health Encounter

Required for All Claims
Field Name
Field
Start
Position
Field
Length
Format
Field Description
Must be HE
Must be H
Health Number
10
N or S
Must satisfy the Mod 10 Check

Digit routine (refer to Section 5.13
MOD 10 Check Digit). Must not
be a number reserved for testing
purposes. If absent, Claim Header
2 must exist.
Not required for RMB Claims
Must be blank for non-patient
encounter claims
Version Code
14
A or S
Version of health card (can be 1 or

2 alpha characters)
A one character version code may
be left or right justified
Required for health number claims
Must be present if version code
appears on health card
Not required for RMB claims
encounter claims
Patients Birthdate
16
D or S
Must be present
encounter claims
Accounting Number
24
Available for use by the health care

provider for claim identification
continued . . .
5-8
5.6

Field Name
Payment Program
Field
Start
Position
Field
Length
Format
32
Field Description
Payee
35
Must be present and one of:

HCP (Health Claims Payment)
WCB (Workplace Safety and
Insurance Board)
RMB (Reciprocal Medical Billings)
Must be HCP for non-patient
encounter claims (refer to Section
5.15 Valid Payment/Payee
Combinations)
Must be present and one of: P
(Provider) or S (Patient)
Must be P (Provider) for
non-patient encounter claims
Referring/
Requisitioning Health
Care Provider Number
36
If required, must be a ministry

assigned health care provider
number
Master Number
42
X/N
Effective April 1, 2006, if required

must be a valid Master Number as
assigned by the ministry in the
current Master Numbering System
book. The Master Number is the
unique number assigned by the
ministry to identify the facility in
which the insured service was
rendered (refer to Section 5.9 Fee
Schedule Code Relationships)
Must be present if the Service
Location Indicator is HDS, HED,
HIP or HOP (refer to Section 5.12
Service Location Indicator Codes)
Not applicable to laboratory claims
continued . . .
5-9

5.6

Field Name
In-Patient Admission
Date
Field
Start
Position
Field
Length
Format
46
Field Description
Effective April 1, 2006, if present,

Admission Date must be the same
as or prior to Service Date (refer to
Section 5.9 Fee Schedule Code
Relationships)
Must be present if Service
Location Indicator is HIP
Must be present for long-term care
facility admission assessment fee
codes
Not applicable to laboratory claims
Referring Laboratory
License Number
54
For laboratory claims if referred

Must be Laboratory Licence
Number assigned by the ministry
Manual Review
Indicator
58
Must be blank or Y. A Y brings

the claim to the attention of the
ministry. Supporting
documentation required (e.g., can
be used to suppress verification
letters).
Service Location
Indicator
59
N or S
Effective April 1, 2006, required for

hospital diagnostic services
Must be three alphas and left
justified
Ministry identifier of the location
where the insured diagnostic
service was provided (refer to
Section 5.12 Service Location
Indicator Codes)
Four numeric continue to be
acceptable for non-hospital
diagnostic services
or A
Reserved for OOC
63
11
Must be spaces unless authorized

by the ministry
Reserved for
MOH Use
74
5 - 10
Must be spaces

5.6

Required for RMB Claims Only
Field Name
Field
Start
Position
Field
Length
Format
Field Description
Must be HE
Must be R
Registration Number
12
Registration numbers less than

12 digits must be left justified
and blank filled
Registration number required for
Reciprocal Medical Claims (refer
to Section 5.14 Province Codes
and Numbering)
Patients Last Name
16
Patients First Name
25
Special characters not accepted

(e.g., quotes, hyphens, imbedded
spaces)
Must be left justified
From health card
Special characters not accepted
(e.g., quotes, hyphens, imbedded
spaces)
Must be left justified
From health card or from patient
Patients Sex
30
Must be 1 for Male or 2 for

Female
Province Code
31
Must be present (refer to Section

5.14 Province Codes and
Numbering)
Reserved for
MOH Use
33
47
Must be spaces
5 - 11

5.6
Item Record Health Encounter

There must be at least one item per claim (Item 1)
Field Name
Field
Start
Position
Field
Length
Format
Field Description
Must be HE
Must be T
Must be present for all claims in

the format ANNNA
Prefix must be alpha, except I, O,
or U
NNN must be numeric
Suffix must be A, B, or C
For Laboratory Claims
Prefix must be L, Suffix must be A
NNN must not be 700 if
Referring Laboratory Licence
Number is present (refer to
Ontario OHIP Schedule of Benefits
and Fees
Item 1
Service Code
Reserved for MOH Use
Must be spaces
Fee Submitted
11
Required for all claims except

laboratory claims
Must be in the range 000000 to
500000 ($$$$cc)
Fee submitted must be a multiple
of the Number of Services
Number of Services
17
Must be within the range 01 to 99

Must divide into Fee Submitted
evenly
continued . . .
5 - 12

5.6
Item Record Health Encounter

There must be at least one item per claim (Item 1)
Field Name
Field
Start
Position
Field
Length
Format
Field Description
Item 1 (continued)
Service Date
Diagnostic Code
19
27
Reserved for OOC
31
10
Reserved for
MOH Use
41
Must be present
Must be less than or equal to the
Creation Date (Batch Identification
field in Batch Header)
Must be no more than 6 months old
If required, must be a valid
Diagnostic Code (refer to Section
5.8 Services Requiring
Diagnostic Codes)
Left justify if 3 digit diagnostic
code is used
Not required for laboratory claims
Must be spaces unless authorized
by ministry
Must be spaces
Item 2 Optional
Service Code
Reserved for
MOH Use
Fee Submitted
42
47
5
2
A
S
49
Number of Services
55
Service Date
57
Diagnostic Code
65
Reserved for OOC
69
10
Reserved for
MOH Use
79
5 - 13
NOTE:
Field Descriptions are the same as

listed under Item 1.
All fields must be spaces if this
optional Item 2 is not used.

5.6
Batch Trailer Record Health Encounter

Last Record of Every Batch
Field Name
Field
Start
Position
Field
Length
Format
Field Description
Must be HE
Must be E
H Count
Must be present
Must be right justified with leading
zeros
Must be total of Claim Header 1
Records within the batch
R Count
T Count
12
Reserved for
MOH Use
17
63
5 - 14
Must be present
zeros
Must be total of Claim Header 2
Records within the batch
Must be present
zeros
Must be total of Item Records
within the batch
Must be spaces
5.7 Specialty Codes

Health Care Provider Specialty Codes
This is a list of specialties or disciplines recognized by the Royal College of Physicians
and Surgeons of Canada relevant to services covered under the Ministry of Health and
Long-Term Care.
Code
00
01
02
03
04
05
06
07
08
09
12
13
18
19
20
22
23
24
26
28
29
30
31
33
34
35
41
47
48
60
61
62
63
64
Physician
Family Practice and Practice In General
Anaesthesia
Dermatology
General Surgery
Neurosurgery
Community Medicine
Orthopaedic Surgery
Geriatrics
Plastic Surgery
Cardiovascular and Thoracic Surgery
Emergency Medicine
Internal Medicine
Neurology
Psychiatry
Obstetrics and Gynaecology
Genetics
Ophthalmology
Otolaryngology
Paediatrics
Pathology
Microbiology
Clinical Biochemistry
Physical Medicine
Diagnostic Radiology
Therapeutic Radiology
Urology
Gastroenterology
Respiratory Diseases
Rheumatology
Cardiology
Haematology
Clinical Immunology
Nuclear Medicine
Thoracic Surgery
5 - 15

5.7
Specialty Codes (continued)
Code
Dental
49
50
51
52
53
54
55
70
71
Dental Surgery
Oral Surgery
Orthodontics
Paedodontics
Periodontics
Oral Pathology
Endodontics
Oral Radiology
Prosthodontics
Code
Practitioner
56
57
58
59
75
80
81
Optometry
Osteopathy
Chiropody (Podiatry)
Chiropractics
Midwife (referral only)
Private Physiotherapy Facility (Approved to Provide Home Treatment Only)
Private Physiotherapy Facility (Approved to Provide Office and Home Treatment)
Code
Other
27
76
85
90
Non-medical Laboratory Director (Provider Number Must Be 599993)

Nurse Practitioner
Alternate Health Care Profession
IHF Non-Medical Practitioner (Provider Number Must Be 991000)
5 - 16
5.8 Services Requiring Diagnostic Codes

Fee Schedule
Codes
Exceptions
AA
A331A, A335A, A338A, A585A, A903A, A990A, A991A,

A994A, A995A, A996A, A997A
BA
B910A, B911A,
B914A-B917A
CA
C101A, C109A, C110A, C335A, C585A, C903A,

C989A-C997A
DA
E015A, E077A
E078A
E100A- E359A
E570A, E687A
FA
G390A, G391A
G395A
G400A-G402A
G405A-G407A
G423A, G424A
G460A, G461A
G521A-G523A
G557A-G559A
G597A-G602A
G610A, G611A
G620A, G621A
G631A, G632A
G634A, G635A
G800A-G805A
HA
H001A, H007A, H106A, H110A, H112A, H113A, H261A,

H267A, H400A - H450A
KA
K009A, K017A, K018A, K021A, K035A, K036A,

K050A- K055A, K061A, K099A, K112A, K267A, K269A,
K400A, K990A-K997A
5 - 17

5.8
Services Requiring Diagnostic Codes (Continued)
Fee Schedule
Codes
Exceptions
MA
NA
PA
P003A-P008A, P016A, P018A, P020A, P025A, P030A,

P041A, P042A
RA
R044A
SA
T100A-T999A
* V101A-V115A
V201A-V203A
V302A-V305A
V402A
V404A-V409A,
V450A, V451A
**V821A to V825A
WA
W010A, W109A, W239A, W269A, W279A, W419A,

W903A, W990A-W997A
Z100A-A429A
Z460A-Z519A
Z521A-Z539A
Z541A-Z561A
Z563A-Z776A
Z778A-Z917A
* These ranges require valid chiropractor diagnostic codes.

** These ranges require valid physiotherapy diagnostic codes.
Diagnostic Codes are detailed in the Resource Manual for Physicians, Section 4.
5 - 18
5.9 Fee Schedule Code Relationships

Summary
The following requirement(s) must be present for the type(s) of services outlined below:
Type of Service
Requirement
All consultations, repeat consultations and limited

consultations rendered in any location
Referring Health Care Provider No.
All non-emergency hospital in-patient services

except consultations, repeat consultations and
limited consultations
Facility No.
In-Patient Admission Date
All consultations in hospital
Facility No.
All long-term institutional care, emergency

department visits, neo-natal care, respiratory care,
low birth weight baby care and attendance at
maternal delivery for the care of a high-risk baby
All claims for Group Psychotherapy for
In-Patients of a Hospital
Facility No.
All special-visit premiums to the Out-Patient

Emergency Department
All special visit premiums to long-term
institutional care
Facility No.
All special-visit premiums to a hospital in-patient
Facility No.
All dental services
Facility No.
All physiotherapy services
All claims for Laboratory Services, X-rays and

other diagnostic procedures rendered in a hospital
or a health facility (including IHF)
Referring/Requisitioning Health
Care Provider No.
All claims for Laboratory Services referred from

one laboratory to another
Referring Laboratory Licence No.
5 - 19

5.9
Fee Schedule Code Relationships (continued)
Table
A Fee Schedule Code
B Referring/ Requisitioning Health Care Provider Number
C Master Number
D In-Patient Admission Date
A005A
A006A
A015A
A016A
A025A
A026A
A035A
A036A
A045A
A046A
A055A
A065A
A066A
A075A
A076A
A085A
A086A
A095A
A096A
A135A
A136A
A185A
A186A
A195A
A196A
A197A
A198A
A205A
A206A
A225A
A226A
A235A
A236A
A245A
A246A
A265A
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
A266A
A285A
A286A
A315A
A316A
A325A
A335A
A345A
A346A
A355A
A356A
A375A
A385A
A395A
A405A
A415A
A416A
A435A
A475A
A476A
A485A
A486A
A515A
A525A
A545A
A565A
A575A
A585A
A586A
A595A
A605A
A606A
A615A
A616A
A625A
A626A
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
A635A
A636A
A645A
A646A
A655A
A665A
A667A
A675A
A695A
A735A
A745A
A775A
A795A
A813A
A815A
A895A
A905A
A935A
A945A
C002A
C003A
C004A
C005A
C006A
C007A
C008A
C009A
C010A
C012A
C013A
C014A
C015A
C016A
C017A
C018A
C019A
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
Y
Y
N
N
N
N
N
N
N
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Y
Y
Y
N
N
Y
Y
Y
Y
Y
Y
Y
N
N
Y
Y
Y
5 - 20
5.9
A Fee Schedule Code

C Master Number
C022A
C023A
C024A
C025A
C026A
C027A
C028A
C029A
C032A
C033A
C034A
C035A
C036A
C037A
C038A
C039A
C042A
C043A
C044A
C045A
C046A
C047A
C048A
C049A
C055A
C062A
C063A
C064A
C065A
C066A
C067A
C068A
C069A
C071A
C072A
C073A
C074A
C075A
C076A
N
N
N
Y
Y
N
N
N
N
N
N
Y
Y
N
N
N
N
N
N
Y
Y
N
N
N
Y
N
N
N
Y
Y
N
N
N
N
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
Y
Y
Y
Y
Y
Y
N
N
Y
Y
Y
Y
Y
Y
N
N
Y
Y
Y
Y
Y
Y
Y
N
N
Y
Y
Y
Y
Y
Y
Y
N
N
C077A
C078A
C079A
C082A
C083A
C084A
C085A
C086A
C087A
C088A
C089A
C092A
C093A
C094A
C095A
C096A
C097A
C098A
C099A
C101A
C109A
C110A
C121A
C131A
C132A
C133A
C134A
C135A
C136A
C137A
C138A
C139A
C181A
C182A
C183A
C184A
C185A
C186A
C187A
N
N
N
N
N
N
Y
Y
N
N
N
N
N
N
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
Y
Y
N
N
N
N
N
N
N
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
Y
Y
Y
Y
Y
Y
N
N
N
Y
Y
N
N
N
Y
Y
Y
Y
Y
N
N
Y
Y
Y
Y
Y
Y
Y
N
N
Y
5 - 21
C188A
C189A
C192A
C193A
C194A
C195A
C196A
C197A
C198A
C199A
C202A
C203A
C204A
C205A
C206A
C207A
C208A
C209A
C215A
C225A
C226A
C232A
C233A
C234A
C235A
C236A
C237A
C238A
C239A
C242A
C243A
C244A
C245A
C246A
C247A
C248A
C249A
C262A
C263A
N
N
N
N
N
Y
Y
N
N
N
N
N
N
Y
Y
N
N
N
Y
Y
Y
N
N
N
Y
Y
N
N
N
N
N
N
Y
Y
N
N
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
Y
Y
Y
Y
Y
Y
N
N
Y
Y
Y
Y
N
N
Y
Y
Y
N
N
Y
Y
Y
Y
Y
Y
N
N
Y
Y
Y
Y
Y

5.9
A Fee Schedule Code

C Master Number
C264A
C265A
C266A
C267A
C268A
C269A
C283A
C285A
C286A
C288A
C311A
C312A
C313A
C314A
C315A
C316A
C317A
C318A
C319A
C325A
C335A
C341A
C342A
C343A
C344A
C345A
C346A
C347A
C348A
C349A
C352A
C353A
C354A
C355A
C356A
C357A
C358A
C359A
C375A
N
Y
Y
N
N
N
N
Y
Y
N
N
N
N
N
Y
Y
N
N
N
Y
Y
N
N
N
N
Y
Y
N
N
N
N
N
N
Y
Y
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
Y
Y
Y
Y
N
N
Y
Y
Y
Y
Y
N
N
Y
Y
Y
N
N
Y
Y
Y
Y
N
N
Y
Y
Y
Y
Y
Y
N
N
Y
Y
Y
N
C385A
C395A
C405A
C411A
C412A
C413A
C414A
C415A
C416A
C417A
C418A
C419A
C435A
C471A
C472A
C473A
C474A
C475A
C476A
C477A
C478A
C479A
C481A
C482A
C483A
C484A
C485A
C486A
C487A
C488A
C489A
C515A
C525A
C545A
C565A
C575A
C585A
C586A
C595A
Y
Y
Y
N
N
N
N
Y
Y
N
N
N
Y
N
N
N
N
Y
Y
N
N
N
N
N
N
N
Y
Y
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
Y
Y
Y
Y
Y
N
N
Y
Y
Y
N
Y
Y
Y
Y
N
N
Y
Y
Y
Y
Y
Y
Y
N
N
Y
Y
Y
N
N
N
N
N
N
Y
N
C601A
C602A
C603A
C604A
C605A
C606A
C607A
C608A
C609A
C611A
C612A
C613A
C614A
C615A
C616A
C617A
C618A
C619A
C621A
C622A
C623A
C624A
C625A
C626A
C627A
C628A
C629A
C635A
C636A
C642A
C643A
C644A
C645A
C646A
C647A
C648A
C649A
C655A
N
N
N
N
Y
Y
N
N
N
N
N
N
N
Y
Y
N
N
N
N
N
N
N
Y
Y
N
N
N
Y
Y
N
N
N
Y
Y
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
Y
Y
Y
Y
Y
Y
Y
N
N
Y
Y
Y
Y
Y
Y
Y
N
N
Y
Y
Y
N
N
Y
Y
Y
N
N
Y
Y
Y
N
5 - 22
5.9
A Fee Schedule Code

C Master Number
C661A
C665A
C667A
C675A
C695A
C735A
C745A
C771A
C775A
C777A
C795A
C882A
C895A
C903A
C905A
C935A
C945A
C982A
C988B
C989A
C990A
C991A
C992A
C993A
C994A
C995A
C996A
C997A
E015A
E101B
E475A
G185A
G400A
G401A
G402A
G405A
G406A
G407A
G557A
N
Y
Y
Y
Y
Y
Y
N
Y
N
Y
N
Y
N
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
Y
N
N
N
N
N
N
N
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
N
Y
N
N
Y
Y
Y
Y
N
N
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
G558A
G559A
G600A
G601A
G602A
G610A
G611A
G620A
G621A
H002A
H003A
H007A
H055A
H065A
H101A
H103A
H104A
H105A
H112A
H113A
H121A
H123A
H124A
H131A
H132A
H133A
H134A
H151A
H153A
H154A
H262A
H263A
H267A
H312A
H317A
H319A
K061A
K191A
K196A
N
N
N
N
N
N
N
N
N
N
N
N
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Y
Y
Y
Y
Y
Y
K199A
K990A
K991A
K992A
K993A
K994A
K995A
K996A
K997A
S900C
T---A
U990A
U991A
U992A
U993A
U994A
U995A
U996A
U997A
V821A
V822A
V823A
V824A
V825A
W001A
W002A
W003A
W004A
W008A
W021A
W022A
W023A
W025A
W026A
W028A
W031A
W032A
W033A
W035A
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
Y
Y
N
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
5 - 23

5.9
A Fee Schedule Code

C Master Number
W036A
W038A
W045A
W046A
W055A
W061A
W062A
W063A
W065A
W066A
W068A
W071A
W072A
W073A
W074A
W075A
W076A
W078A
W085A
W086A
W095A
W096A
W102A
W104A
W105A
W106A
W107A
W109A
W121A
W131A
W132A
W133A
W134A
W138A
W181A
W182A
W183A
W184A
W185A
W186A
W188A
Y
N
Y
Y
Y
N
N
N
Y
Y
N
N
N
N
N
Y
Y
N
Y
Y
Y
Y
N
N
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Y
Y
N
N
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
W195A
W196A
W225A
W226A
W232A
W234A
W235A
W236A
W237A
W239A
W261A
W262A
W265A
W266A
W269A
W272A
W274A
W277A
W279A
W305A
W306A
W310A
W311A
W312A
W313A
W314A
W318A
W325A
W345A
W346A
W355A
W356A
W375A
W385A
W395A
W405A
W419A
W435A
W512A
W514A
W515A
Y
Y
Y
Y
N
N
Y
Y
N
N
N
N
Y
Y
N
N
N
N
N
Y
Y
Y
N
N
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
Y
Y
N
N
Y
N
N
N
N
N
N
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Y
Y
N
W516A
W517A
W535A
W536A
W562A
W564A
W565A
W567A
W645A
W646A
W667A
W695A
W771A
W775A
W777A
W795A
W872A
W882A
W895A
W903A
W972A
W982A
W990A
W991A
W992A
W993A
W994A
W995A
W996A
W997A
Z777A
Y
N
Y
Y
N
N
Y
N
Y
Y
Y
Y
N
Y
N
Y
N
N
Y
N
N
N
N
N
N
N
N
N
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
N
N
Y
Y
N
Y
N
N
N
N
N
N
N
N
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
5 - 24
5.9
NOTE:
1. A referring/requisitioning Health Care Provider number is required for all claims

that are billed by Independent Health Facilities that are either grandfathered, or
licensed with group numbers within the series AAAA A999.
2. A referring/requisitioning Health Care Provider number is required for claims that

are billed by groups with the following numbers, or such claims will reject under
Review Error Condition V09 Invalid Referral Number
- Begins with 5 or 7.
- Within the series 8000 8599, 8600 8999.
- 6008, 6100 or 9xxx.
The aforementioned list does not include the entire Ministry of Health and Long-Term Care
insured services. The Fee Schedule Code Relationships Table only lists those Fee Schedule
Codes, which require a referring/requisitioning health care provider number, a facility number,
and/or an in-patient admission date.
5 - 25
5.10 Fee Schedule Code Suffix B/C Exceptions

When the Fee Schedule Code Suffix is B or C the number of services must be
greater than 01.
Exceptions to the above are:
C988B
C998B,C
C999B,C
E005C
E052C
E101B
E475C
E757C
E007C
E054C
E400B,C
E505C
E787C
E008C
E055C
E401B,C
E572C
E850C
E009C
E056C
E450B,C
E721C
E955C
E049C
E100C
E451B,C
E722C
G176B
G254B
G266B
G290B
G296B
G301B
G366B
G177B
G261B
G267B
G291B
G297B
G305B
G509B
G178B
G262B
G286B
G292B
G298B
G306B
G518B
G179B
G263B
G288B
G293B
G299B
G321B
G519B
G249B
G265B
G289B
G294B
G300B
G322B
J100B,C
J400C
J407B,C
J428B,C
J463B,C
J489C
J490B
J500B,C
J602B,C
J802B,C
J894B
TO
J402B,C
J408B,C
J435B,C
J464B,C
TO
TO
TO
TO
TO
J399B,C
J403B,C
J422B,C
J438B,C
J480B,C
J498C
J498B
J507B,C
J689B,C
J889B,C
INCLUSIVE
J405B,C
J425B,C
J459B,C
J482B,C
J406B,C
J427B,C
J462B,C
J483B,C
INCLUSIVE
INCLUSIVE
P015C
X___B
X___C
Y602B,C
Y802B,C
TO
TO
Y689B,C
Y889B,C
INCLUSIVE
INCLUSIVE
Z431B
Z442B
Z434B
Z443B
Z439B
Z448B
Z440B
Z449B
5 - 26
Z441B
Z459C
5.11 Service Codes

Prior Authorization
The following is a list of service codes for which prior authorization is required:
E200
R026-R028
T901-T912
E201
R110
T925-T928
M013
R112
T936
M014
R319
T950
M019
R320
M024
S318
Supporting Documentation
The following is a list of service codes for which supporting documentation (e.g.,
clinical records, operative reports) may be requested:
A935
E410
E555
E911
F130
G424
K101
M011
R007
R064-R069
R106
R125-R139
R434
R637
R993
S619
T525
T810
Z155
C121
E411
E556
E925
F131
G800-G805
L299
M033
R025
R074
R113
R150-R154
R523
R638
S015
S708
T565
W121
Z165
E304
E531
E564
E958
F146
J041
L585
M109
R029
R081-R083
R114
R214
R528
R671
S021
S726
T567-T570
X486
Z191
E307
E532
E569
E977
G272
K001
L611
M110
R051
R086-R088
R118
R272
R604
R674
S293
S900
T618
Z100
Z848
5 - 27
E308
E540
E586
F124
G383
K018
L690
M400
R057
R091
R120
R352
R605
R829
S316
T230
T800
Z148
E409
E544
E906
F125
G423
K021
L693
R004
R058
R104
R121
R360
R635
R990
S418
T371
T809
Z152
5.12 Service Location Indicator Codes

Effective April 1, 2006 the four acceptable Service Location Indicator codes are:
Code
Description
HDS
HED
HIP
HOP
Hospital Day Surgery

Hospital Emergency Department
Hospital In-Patient
Hospital Out-Patient
The Service Location Indicator is a generic field and the ministry may introduce SLI codes for
other settings in the future to support data collection for planning and forecasting purposes.
Diagnostic Services Fee Codes

The professional fee codes that can be billed as of April 1, 2006 by physicians for diagnostic
services rendered to hospital in-patients and that require the HIP Service Location Indicator code
are listed in the Schedule of Benefits for Physician Services in the following sections:
Nuclear Medicine In Vivo (Section B)

Diagnostic Radiology (Section D)
Magnetic Resonance Imaging (Section F)
Diagnostic Ultrasound (Section G)
Pulmonary Function Studies (Section H)
Diagnostic and Therapeutic Procedures (Section J)
5 - 28
5.12 Service Location Indicator Codes (continued)
Hospital diagnostic services that will require a Service Location Indicator commencing April 1,
2006 and no later than October 1, 2006:
A1:
A2:
A3:
A4:
A1.
J602C
J604C
J606C
J607C
J608C
J609C
J610C
J611C
J612C
J613C
J614C
J615C
J616C
J617C
J618C
J619C
J620C
J621C
J623C
J624C
J625C
J626C
J627C
J629C
J630C
J631C
J632C
J633C
J634C
J635C
J636C
J637C
J638C
J639C
J640C
J641C
J643C
J647C
J648C
J649C
J650C
Nuclear Medicine In Vivo

Diagnostic Ultrasound
Pulmonary Function Studies
A5: Magnetic Resonance Imaging

A6: Diagnostic and Therapeutic Procedures
A7: Technical Fee Codes
Nuclear Medicine in Vivo

J651C
J652C
J653C
J654C
J655C
J656C
J657C
J658C
J659C
J660C
J661C
J662C
J663C
J664C
J665C
J666C
J667C
J668C
J669C
J670C
J671C
J672C
J673C
J674C
J675C
J676C
J677C
J678C
J679C
J680C
J681C
J682C
J683C
J684C
J685C
J686C
J687C
J688C
J802C
J804C
J806C
J807C
J808C
J809C
J810C
J811C
J812C
J813C
J814C
J815C
J816C
J817C
J818C
J819C
J820C
J821C
J823C
J824C
J825C
J826C
J827C
J829C
J830C
J831C
J832C
J833C
J834C
J835C
J836C
J837C
J838C
J839C
J840C
J841C
J843C
J847C
J848C
J849C
J850C
J851C
J852C
J853C
J854C
J855C
J856C
J857C
J858C
J859C
J860C
J861C
J862C
J863C
J864C
J865C
J866C
J867C
J868C
J869C
J870C
J871C
J872C
J873C
J874C
J875C
J876C
J877C
J878C
J879C
J880C
J881C
J882C
J883C
J884C
J885C
J886C
J887C
J888C
Y602C
Y604C
Y606C
Y607C
Y608C
Y609C
Y610C
Y611C
Y612C
Y613C
Y614C
Y615C
Y616C
Y617C
Y618C
Y620C
Y621C
Y623C
Y624C
Y625C
Y626C
Y627C
Y629C
Y630C
Y631C
Y632C
Y633C
Y634C
Y635C
Y636C
Y637C
Y638C
Y639C
Y640C
Y641C
Y643C
Y647C
Y648C
Y649C
Y650C
Y651C
Y652C
Y653C
Y654C
Y655C
Y656C
Y657C
5 - 29
Y658C
Y659C
Y660C
Y661C
Y662C
Y663C
Y664C
Y665C
Y667C
Y668C
Y669C
Y670C
Y671C
Y672C
Y673C
Y674C
Y675C
Y676C
Y677C
Y678C
Y679C
Y680C
Y681C
Y682C
Y683C
Y684C
Y685C
Y686C
Y687C
Y688C
Y802C
Y804C
Y806C
Y807C
Y808C
Y809C
Y810C
Y811C
Y812C
Y813C
Y814C
Y815C
Y816C
Y817C
Y818C
Y820C
Y821C
Y823C
Y824C
Y825C
Y826C
Y827C
Y829C
Y830C
Y831C
Y832C
Y833C
Y834C
Y835C
Y836C
Y837C
Y838C
Y839C
Y840C
Y841C
Y843C
Y847C
Y848C
Y849C
Y850C
Y851C
Y852C
Y853C
Y854C
Y855C
Y856C
Y857C
Y858C
Y859C
Y860C
Y861C
Y862C
Y863C
Y864C
Y865C
Y867C
Y868C
Y869C
Y870C
Y871C
Y872C
Y873C
Y874C
Y875C
Y876C
Y877C
Y878C
Y879C
Y880C
Y881C
Y882C
Y883C
Y884C
Y885C
Y886C
Y887C
Y888C
A2.
X001C
X057C
X128C
X175C
X217C
X003C
X058C
X129C
X176C
X218C
X004C
X060C
X130C
X177C
X219C
X005C
X063C
X131C
X179C
X220C
X006C
X064C
X132C
X180C
X221C
X007C
X065C
X133C
X181C
X223C
X008C
X066C
X134C
X182C
X224C
X009C
X067C
X135C
X183C
X225C
X010C
X068C
X136C
X184C
X226C
X011C
X069C
X137C
X185C
X227C
X012C
X072C
X138C
X186C
X228C
X016C
X080C
X139C
X187C
X229C
X017C
X081C
X140C
X188C
X230C
X018C
X090C
X141C
X189C
X231C
X019C
X091C
X143C
X190C
X232C
X020C
X092C
X144C
X191C
X233C
X025C
X096C
X147C
X192C
X400C
X027C
X100C
X149C
X193C
X401C
X028C
X101C
X150C
X194C
X402C
X031C
X103C
X151C
X195C
X403C
X032C
X104C
X152C
X196C
X404C
X033C
X105C
X153C
X197C
X405C
X034C
X106C
X154C
X198C
X406C
X035C
X107C
X155C
X199C
X407C
X036C
X108C
X156C
X200C
X408C
X037C
X109C
X157C
X201C
X409C
X038C
X110C
X158C
X202C
X410C
X039C
X111C
X159C
X203C
X412C
X040C
X112C
X160C
X204C
X413C
X045C
X113C
X161C
X205C
X415C
X046C
X114C
X162C
X206C
X416C
X047C
X116C
X163C
X207C
X417C
X048C
X117C
X164C
X208C
X049C
X120C
X165C
X209C
X050C
X121C
X167C
X210C
X051C
X122C
X168C
X211C
X052C
X123C
X169C
X212C
X053C
X124C
X170C
X213C
X054C
X125C
X171C
X214C
X055C
X126C
X173C
X215C
X056C
X127C
X174C
X216C
5 - 30
A3.
A4.
Diagnostic Ultrasound
J122C
J422C
J102C
J402C
J103C
J403C
J107C
J407C
J108C
J408C
J105C
J405C
J106C
J406C
J125C
J425C
J135C
J435C
J128C
J428C
J159C
J459C
J160C
J460C
J157C
J457C
J158C
J458C
J162C
J462C
J138C
J438C
J165C
J163C
J463C
J161C
J461C
J164C
J464C
J476C
J189C
J489C
J190C
J490C
J191C
J491C
J192C
J492C
J201C
J501C
J193C
J493C
J194C
J494C
J195C
J495C
J202C
J502C
J198C
J498C
J205C
J505C
J206C
J506C
J207C
J507C
J200C
J500C
J196C
J496C
J197C
J497C
J203C
J503C
J204C
J504C
J180C
J480C
J182C
J482C
J127C
J427C
J183C
J483C
J290C
J149C
J151C
Pulmonary Function Studies

J301C
J324C
J304C
J327C
J311C
J307C
J305C
J306C
J303C
J340C
J310C
J308C
J315C
E450C
E451C
J316C
J330C
J320C
J331C
J313C
J332C
J334C
J322C
J333C
J335C
5 - 31
A5.
A6.
Magnetic Resonance Imaging (MRI)

X421C
X425C
X431C
X435C
X441C
X445C
X451C
X455C
X461C
X465C
X471C
X475C
X488C
X489C
X490C
X492C
X493C
X495C
X496C
X498C
X486C
X487C
X499C
Diagnostic and Therapeutic Procedures

G105A
G197A
G353A
G457A
G561A
G660A
G112A
G251A
G354A
G459A
G562A
G690A
G120A
G252A
G415A
G469A
G567A
G816A
G138A
G253A
G418A
G477A
G568A
J689C
G139A
G283A
G425A
G516A
G571A
J690C
G141A
G307A
G428A
G518A
G572A
J691C
G142A
G313A
G432A
G525A
G575A
J889C
G144A
G317A
G433A
G526A
G578A
J890C
G145A
G319A
G436A
G529A
G581A
J891C
G147A
G320A
G437A
G530A
G650A
J893C
G148A
G321A
G438A
G533A
G653A
J894C
G150A
G343A
G439A
G545A
G656A
G151A
G346A
G444A
G546A
G657A
G166A
G350A
G450A
G555A
G658A
G180A
G351A
G456A
G560A
G659A
5 - 32
A7.
Technical Fee Codes
The following technical-fee diagnostics services are not billable for hospital in-patient (HIP)
services but can be submitted with all other SLI codes as applicable:
E450B
G683A
J191B
J406B
J611B
J662B
J819B
J870B
X033B
E451B
G684A
J192B
J407B
J612B
J663B
J820B
J871B
X034B
X110B
G104A
G685A
J193B
J408B
J613B
J664B
J821B
J872B
X035B
X111B
G111A
G686A
J194B
J422B
J614B
J665B
J823B
J873B
X036B
X112B
G121A
G687A
J195B
J425B
J615B
J666B
J824B
J874B
X037B
X113B
G140A
G688A
J196B
J427B
J616B
J667B
J825B
J875B
X038B
X114B
G143A
G689A
J197B
J428B
J617B
J668B
J826B
J876B
X039B
X116B
G146A
G692A
J198B
J435B
J618B
J669B
J827B
J877B
X040B
X117B
G149A
G693A
J200B
J438B
J619B
J670B
J829B
J878B
X045B
X120B
G152A
G815A
J201B
J457B
J620B
J671B
J830B
J879B
X046B
X121B
G167A
G850A
J202B
J458B
J621B
J672B
J831B
J880B
X047B
X122B
G174A
G851A
J203B
J459B
J623B
J673B
J832B
J881B
X048B
X123B
G181A
G852A
J204B
J460B
J624B
J674B
J833B
J882B
X049B
X129B
G209A
G853A
J205B
J461B
J625B
J675B
J834B
J883B
X050B
X130B
G284A
G854A
J206B
J462B
J626B
J676B
J835B
J884B
X051B
X131B
G308A
G855A
J207B
J463B
J627B
J677B
J836B
J885B
X052B
X132B
G310A
G856A
J301B
J464B
J629B
J678B
J837B
J886B
X053B
X133B
G311A
G857A
J303B
J476B
J630B
J679B
J838B
J887B
X054B
X134B
G315A
G858A
J304B
J480B
J631B
J680B
J839B
J888B
X055B
X135B
G414A
J102B
J305B
J482B
J632B
J681B
J840B
J889B
X056B
X136B
G416A
J103B
J306B
J483B
J633B
J682B
J841B
J890B
X057B
X137B
G440A
J105B
J307B
J490B
J634B
J683B
J843B
J891B
X058B
X138B
G441A
J106B
J308B
J491B
J635B
J684B
J847B
J893B
X060B
X139B
G442A
J107B
J310B
J492B
J636B
J685B
J848B
J894B
X063B
X140B
G443A
J108B
J311B
J493B
J637B
J686B
J849B
X001B
X064B
X141B
G448A
J122B
J313B
J494B
J638B
J687B
J850B
X003B
X065B
X143B
G451A
J125B
J315B
J495B
J639B
J688B
J851B
X004B
X066B
X144B
G455A
J127B
J316B
J496B
J640B
J689B
J852B
X005B
X067B
X147B
G466A
J128B
J318B
J497B
J641B
J690B
J853B
X006B
X068B
X149B
G519A
J135B
J319B
J498B
J643B
J691B
J854B
X007B
X069B
X150B
G540A
J138B
J320B
J500B
J647B
J802B
J855B
X008B
X072B
X151B
G542A
J149B
J322B
J501B
J648B
J804B
J856B
X009B
X080B
X152B
G544A
J157B
J323B
J502B
J649B
J806B
J857B
X010B
X081B
X153B
G554A
J158B
J324B
J503B
J650B
J807B
J858B
X011B
X090B
X154B
G560A
J159B
J327B
J504B
J651B
J808B
J859B
X012B
X091B
X155B
G566A
J160B
J330B
J505B
J652B
J809B
J860B
X016B
X092B
X156B
G570A
J161B
J331B
J506B
J653B
J810B
J861B
X017B
X096B
X157B
G574A
J162B
J332B
J507B
J654B
J811B
J862B
X018B
X100B
X158B
G577A
J163B
J333B
J602B
J655B
J812B
J863B
X019B
X101B
X159B
G651A
J164B
J334B
J604B
J656B
J813B
J864B
X020B
X103B
X160B
G652A
J165B
J335B
J606B
J657B
J814B
J865B
X025B
X104B
X161B
5 - 33
X109B

G654A
J180B
J340B
J607B
J658B
J815B
J866B
X027B
X105B
X162B
G655A
J182B
J402B
J608B
J659B
J816B
J867B
X028B
X106B
X163B
G661A
J183B
J403B
J609B
J660B
J817B
J868B
X031B
X107B
X164B
G682A
J190B
J405B
J610B
J661B
J818B
J869B
X032B
X108B
X167B
X169B
X214B
Y633B
Y680B
Y847B
X170B
X215B
Y634B
Y681B
Y848B
X171B
X216B
Y635B
Y682B
Y849B
X173B
X217B
Y636B
Y683B
Y850B
X174B
X218B
Y637B
Y684B
Y851B
X175B
X219B
Y638B
Y685B
Y852B
X176B
X220B
Y639B
Y686B
Y853B
X177B
X221B
Y640B
Y687B
Y854B
X179B
X223B
Y641B
Y688B
Y855B
X180B
X224B
Y643B
Y802B
Y856B
X181B
X225B
Y647B
Y804B
Y857B
X182B
X226B
Y648B
Y806B
Y858B
X183B
X227B
Y649B
Y807B
Y859B
X184B
X228B
Y650B
Y808B
Y860B
X185B
X229B
Y651B
Y810B
Y861B
X186B
X230B
Y652B
Y811B
Y862B
X187B
Y602B
Y653B
Y812B
Y863B
X189B
Y604B
Y654B
Y813B
Y864B
X190B
Y606B
Y655B
Y814B
Y865B
X191B
Y607B
Y656B
Y815B
Y867B
X192B
Y608B
Y657B
Y816B
Y868B
X193B
Y610B
Y658B
Y817B
Y869B
X194B
Y611B
Y659B
Y818B
Y870B
X195B
Y612B
Y660B
Y820B
Y871B
X196B
Y613B
Y661B
Y821B
Y872B
X197B
Y614B
Y662B
Y823B
Y873B
X198B
Y615B
Y663B
Y824B
Y874B
X199B
Y616B
Y664B
Y825B
Y875B
X200B
Y617B
Y665B
Y826B
Y876B
X201B
Y618B
Y667B
Y827B
Y877B
X202B
Y620B
Y668B
Y829B
Y878B
X203B
Y621B
Y669B
Y830B
Y879B
X204B
Y623B
Y670B
Y833B
Y880B
X205B
Y624B
Y671B
Y834B
Y881B
X206B
Y625B
Y672B
Y835B
Y882B
X207B
Y626B
Y673B
Y836B
Y883B
X208B
Y627B
Y674B
Y837B
Y884B
X209B
Y628B
Y675B
Y838B
Y885B
X210B
Y629B
Y676B
Y839B
Y886B
X211B
Y630B
Y677B
Y840B
Y887B
X212B
Y631B
Y678B
Y841B
Y888B
X213B
Y632B
Y679B
Y843B
5 - 34
5.13 MOD 10 Check Digit

In order to reduce the number of rejected claims, it is recommended that the health number is
verified by the MOD 10 Check Digit.
Health Number Example
DIGIT POSITION
10
Check
(7) Digit
Double 1st, 3rd,

5th, 7th and 9th Digits
(1+8)*
(1+4)*
(1+0)*
Add The Unit Position

Numbers Across
Health Number
Validation
= 4(3)**
Subtract The
Unit Position From Ten
10
-3
The Check Digit is (7) therefore the Health Number 9876543217 is valid.
(7)
Health Care Provider Number

Effective May 1995, the MOD 10 Check Digit routine formerly used in the verification of health
care provider numbers was removed from all ministry systems. Provider numbers issued after
May 1995, do not contain a check digit.
5 - 35
5.14 Province Codes and Numbering

Province
Prov
Code
Format
Alberta
Prior to May 24/94
11 numerics (May/94 to Oct./94
either 9 or 11 acceptable
AB
9 numerics-individual registration
(Effective Oct. 1/94)
British Columbia
Prior to Jan. 1/91
10 or 11 numerics family based
BC
(Effective Jan. 1/91)
Manitoba
Prior to April 1/2005
6 numerics subscriber or family
based group
MB
9 numerics- individual registration

(Effective Apr 1/2005)
Newfoundland/Labrador
NL
New Brunswick
NB
Northwest Territories
NT
8 character-individual registration
ONE alpha N, D, M or T and 7 numerics
Nova Scotia
Prior to Jan. 1/94
11 numerics family based
NS
Ontario
Prior to Jan. 1/91
ON
10 numerics-individual registration plus 2

character version code (if applicable)
Prince Edward Island

Prior to Jan. 1/96
9 numerics SIN individual
PE
(Effective Dec. 1/96)
Saskatchewan
Prior to Apr. 1/91
SK
(Effective Apr. 1/91)
Territory of Nunavut
NU
Yukon
YT
NOTE:
The Province of Quebec does not participate fully in the Reciprocal Medical Billing
System. Claims for Quebec residents cannot be submitted on MRI.
5 - 36
5.15 Valid Payment Program/Payee Combinations
Payment Program
Payee
HCP
HCP
WCB
RMB
All other combinations are invalid.
Legend
Payment Program
HCP = Health Claims Payment
WCB = Workplace Safety and Insurance
RMB = Reciprocal Medical Billing
Payee
P
S
=
=
Provider
Patient
5 - 37
5.16 Workplace Safety and Insurance Board

(WSIB- formerly referred to as WCB)
Input Conditions
WCB related medical services must be submitted to the ministry for payment (refer to Section
5.11 Service Codes) to identify service codes which require supporting documentation).
The following services are excluded from WCB submissions:
Service codes prefixed by T or V

Laboratory services provided by private medical laboratory facilities
(health care provider group number range 5000 5999)
Services provided by hospital diagnostic departments
(health care provider clinic number range 8600 9999)
Services provided by OPTED-OUT health care providers
5 - 38
6. MACHINE READABLE
OUTPUT SPECIFICATIONS
6.1
Remittance Advice............................................................................................. 6 - 1
6.2
Remittance Advice Data Sequences .................................................................. 6 - 1
6.3
File Naming Convention.................................................................................... 6 - 3
6.4
Format Summary ............................................................................................... 6 - 4
6.5
MRO Record Layouts ........................................................................................ 6 - 6
6.6
Accounting Transactions for Record Type 7 ................................................... 6 - 18
6.7
Remittance Advice Explanatory Codes ........................................................... 6 - 19
6. Machine Readable Output (MRO) Specifications

6.1 Remittance Advice
A Remittance Advice (RA) is a monthly statement of approved claims and is issued at the time of
payment. The RA file contains accounting details of claims approved during the ministrys previous
claims processing cycle. It will also contain explanatory codes to clarify payment exceptions (refer
to Section 6.7 Remittance Advice Explanatory Codes).
The RA may also contain general bulletins or messages from the ministry. The file is available in
several different sort sequences, such as Accounting Number.
6.2 Remittance Advice Data Sequences

The Remittance Advice (RA) is available in 4 sequences as follows:
Paper or MRO
Sort Keys
RA
Type 4
Health Care Provider Group

Number
MOH Office Code
RA
Type 5
RA
Type 6
RA
Type 7
1
1
(3)
Patients Last Name (not

available for MRO)
Accounting Number
Health/
Registration Number
Claim Number
NOTE: 1 = primary sort field
6-1

6.2
Remittance Advice Data Sequences (continued)
RA Type 4:
ACCOUNTING NUMBER Sort for Health Care Provider Groups
The file is sorted by Health Care Provider within the Group. If the Health Care
Provider had service encounters processed in more than one ministry office, the
service encounters are further sorted by ministry Office Code. Within the above sorts,
the service encounters are sorted by: Health Care Provider Accounting Number,
Health/Registration Number and Service Encounter Number.
RA Type 5:
ACCOUNTING NUMBER Sort for Solo Health Care Providers
If the Health Care Provider had service encounters processed in more than one ministry
office, the service encounters are sorted by ministry Office Code. Within the above sort,
the service encounters are sorted by: Health Care Provider Accounting Number,
Health/Registration Number and Service Encounter Number.
RA Type 6:
HEALTH/REGISTRATION NUMBER
The file is sorted by: Health/Registration Number and Service Encounter Number.
RA Type 7:
ACCOUNTING NUMBER Sort for Health Care Provider Groups
The file is sorted by Heath Care Provider within the Group. Within the above sort, the
service encounters are sorted by: Health Care Provider Accounting Number,
Health/Registration Number and Service Encounter Number. The sort hierarchy
within the Accounting Number is: blanks, alphas, numerics.
A health care provider submitting claims in MRI form receives a RA from the ministry in MRO
form. The provider receives a file containing the data related to the RA on the same medium as the
automated claims submission. The MRO format permits health care providers to reconcile accounts
easily and quickly.
The diskette or cartridge containing the RA file may be sent either to the health care provider or
billing agent. The diskette or tape cartridge remains the property of the ministry. The health care
provider must return it promptly to the appropriate ministry office after reconciliation is completed.
One RA file is created for each health care provider for every claims processing cycle regardless of
the number of submissions or input media within that cycle.
6-2
6.3 File Naming Convention

EDT and 3.5" Diskettes
Output file will have file names in the following format:
P
Month
Example:
Field 1
Field 2
Field 3
Field 4
Group Number or Provider Number
Sequence Number
PA123456.001 or PA1234.001
P represents the output indicator

Health care providers registered group number
or solo health care provider number
Three digit sequence number assigned by
the ministry
3490 Tape Cartridges
3490 tape cartridges must use standard labels with file name
HESK.MPRO.CARTRDGE
File compression is now available via Electronic Data Transfer (EDT) for the
Remittance Advice (RA).
The extension of the compressed file received in the EDT mailbox will be .zip (refer to Electronic
Data Transfer File Compression).
6-3
6.4 Format Summary

Record
Type
Description
File Header
Health care provider information
Address Record 1
Name and address Line 1 of billing agent as recorded with the ministry
or
Address Line 1 of the health care provider as recorded with the ministry
Address Record 2
Address Lines 2 and 3 of billing agent (if billing agents name present in Address
Record 1) or of health care provider
Claim Header
Common control information for each claim
Claim Item
Detailed information for each item of service within a claim (e.g., service code,
service date, amounts)
Balance Forward
This record is present only if the previous months remittance was NEGATIVE.
It indicates any amounts brought forward from the previous month by category
(e.g., claim adjustments, advances, reductions).
Accounting Transaction
This record is present only if an accounting transaction is posted to the remittance
advice (e.g., advance, reduction, advance payment).
The sum of the fees paid for approved RMB claims will also appear as an
accounting transaction.
Message Facility
A facility for the ministry to send messages to all or selected health care
providers. This record may or may not be present. If present, can have up to
99,999 occurrences.
Claims that are processed in the Reciprocal Medical Billing (RMB) system will be included with the
regular Remittance Advice data. The RMB records (claim headers and items) appear at the end of
the file, after all other non-RMB records.
6-4

6.4
Format Summary (continued)
Health Reconciliation Sample

HR5
CLAIM ITEM (RMB)
HR4
HR5
HR4
HR8
HR8
HR8
CLAIM HEADER (RMB)

CLAIM ITEM (RMB)
CLAIM HEADER (RMB)

MESSAGE FACILITY
MESSAGE FACILITY
MESSAGE FACILITY
HR7 ACCOUNTING TRANSACTION

HR6
HR5
HR5
BALANCE FORWARD
CLAIM ITEM (HCP/WCB)
CLAIM ITEM (HCP/WCB)
HR4 CLAIM HEADER (HCP/WCB)

HR3
HR2
HR1
ADDRESS RECORD 2
ADDRESS RECORD 1
FILE HEADER
Fixed Record Length: 79 Characters

6-5
6.5 MRO Record Layouts

Health Reconciliation
Format Legend
A = Alphabetic
N = Numeric
X = Alphanumeric
D = Date (YYYYMMDD)
S = Spaces
NOTES:
All alphabetic characters will be upper-case unless otherwise stated.
The last 2 digits of all the amount fields are cents ().
Refer to Section 5.6 MRI Record Layouts for additional field
description details, where applicable.
6-6

6.5
MRO Record Layout (continued)
File Header Record Health Reconciliation

Occurs Once in Every File Always the First Record
Field
Start
Position
Field
Length
Format
Transaction
Identifier
Always HR
Record Type
Always 1
Tech Spec Release

Identifier
Always V03
Reserved for
MOH Use
Always 0 (zero)
Group Number or
Laboratory Licence
No.
Health Care
Provider/ Physio
Facility/
Laboratory
Director No.
12
Specialty
18
MOH Office Code
20
Remittance Advice
Data Sequence
21
Number representing sort

sequence
Payment Date
22
Payee Name
30
30
Cheque or direct bank deposit

date
Name of Payee as registered with
the ministry - Subdivided for
solo Health Care Providers as
follows:
-Last Name (25)
-Title (3)
-Initials (2)
Field Name
Field Description
A space if no HR 4/5 records,

otherwise it will be numeric
continued . . .
6-7
6.5
File Header Record Health Reconciliation

Occurs Once in Every File Always the First Record
Field
Start
Position
Field
Length
Format
Total Amount
Payable
60
Accumulation of the Amount

Paid for all claim items
appearing on the remittance
advice Plus and/or Minus any
Accounting Transactions and
Balance Forward amounts.
Total Amount
Payable Sign
69
S or X
Space if Total Amount Payable

is positive
Negative (-) sign if Total
Amount Payable is negative
Field Name
Field Description
Cheque Number
Reserved for
MOH Use
70
78
6-8
Pay Provider: number of the

cheque or all 9s if Direct Bank
Deposit
Pay Patient: spaces
Spaces
6.5
Address Record One Health Reconciliation

Occurs Once in Every File Always the Second Record
Field Name
Field
Start
Position
Field
Length
Format
Always HR
Record Type
Always 2
Billing Agents
Name
30
Spaces if a Billing Agent is not

registered for this Health Care
Provider/ group
Address Line One
34
25
Address Line 1 of Health Care

Provider/group or Address Line 1
of Billing Agent
As registered with the ministry
Spaces
Reserved for
MOH Use
59
21
6-9
Field Description
6.5
Address Record Two Health Reconciliation

Occurs Once in Every File Always the Third Record
Field Name
Field
Start
Position
Field
Length
Format
Always HR
Record Type
Always 3
Address Line 2
25
Address Line 3
29
25
Reserved for
MOH Use
54
26
Spaces
6 - 10
Field Description
6.5
Claim Header Record Health Reconciliation

Multiple Records Occurs Once for Each Claim in a File
Field Name
Field
Start
Position
Field
Length
Format
Always HR
Record Type
Always 4
Claim Number
11
Ministry reference number
Transaction Type
15
1 (original claim) or 2
(adjustment to original claim)
Health Care
Provider/ Physio
Facility/ Laboratory
Director No.
16
Specialty
22
Health Care Providers Specialty

Code as on Health Encounter
Claim Header-1
Accounting Number
24
Accounting number as on Health

Encounter Claim Header 1
Patients Last Name
32
14
S or A
Spaces except for RMB claims
Patients First Name

(First five characters)
46
S or A
Spaces except for RMB claims
Province Code
51
Refer to Section 5.14 Province

Codes and Numbering
Health Registration
Number
53
12
X or S
Left justified
Field Description
continued . . .
6 - 11
6.5
Claim Header Record Health Reconciliation

Field
Start
Position
Field
Length
Format
Version Code
65
A or S
Version code as on Health

Payment Program
67
Payment program as on Health

Location Code
70
N or S
4 numerics or spaces
Location Code as on Health
MOH Group
74
MOH Group Number Identifier
Field Name
Field Description
Identifier
Reserved for
MOH Use
Information for redirection to

78
6 - 12
Spaces
6.5
Claim Item Record Health Reconciliation

Multiple Records Occurs Once for Each Item in a Claim
Field Name
Field
Start
Position
Field
Length
Format
Always HR
Record Type
Always 5
Claim Number
11
Ministry reference number
Transaction Type
15
1 (original claim) or 2
(adjustment to original claim)
Service Date
16
Service date as on Health

Encounter Item Record
Number of Services
24
Number of Services as on Health

Service Code
26
Reserved for
MOH Use
31
Spaces
Amount Submitted
32
Amount submitted as on Health

Amount Paid
38
Amount Paid Sign
44
S or X
Space if Amount Paid is positive

Negative (-) sign if Amount Paid
is negative
Explanatory Code
45
Refer to Section 6.7 Remittance

Advice Explanatory Codes
Reserved for
MOH Use
47
33
Spaces
Field Description
continued . . .
6 - 13
6.5
Balance Forward Record Health Reconciliation

Occurs Once for Each File
(only if previous months payment was negative)
Field Name
Field
Start
Position
Field
Length
Format
Always HR
Record Type
Always 6
Amount Brought
Forward Claims
Adjustment
Field will contain a value other

than zeros when the Total
Remittance Payable does not
exceed the total debit items for
adjusted claims. The debit items
are deducted from the Total
Remittance Payable starting with
the oldest debit. If the Total
Remittance Payable is reduced to
ZERO, the remaining debits are
summarized and appear as a
Record Type 6 (Amount Brought
Forward Claims Adjustments)
on the next months remittance.
This amount is always negative.
Amount Brought
Forward Claims
Adjustment Sign
13
S or X
Field will be a space if the

Claims Adjustment field contains
zeros, otherwise, it will be a
negative
(-) sign.
Amount Brought
Forward Advances
14

than zeros when a Record Type 7
(Transaction Code 10
Advance) on a previous
Remittance Advice fails to
recover the full value of an
advance. The Amount Brought
Forward is the unrecovered
amount and is always negative.
Field Description
continued . . .
6 - 14
6.5
Balance Forward Record Health Reconciliation

Occurs Once for Each File
(only if previous months payment was negative)
Field
Start
Position
Field
Length
Format
Amount Brought
Forward Advances
Sign
23
S or X

Advances field contains zeros,
otherwise it will be a negative (-)
sign.
Amount Brought
Forward
Reductions
24

than zeros when a Record Type 7
(Transaction Code 20
Reduction) on a previous
Remittance Advice cannot be
satisfied by the Total Remittance
Payable. The Amount Brought
Forward is the unrecovered
amount and is always negative.
Amount Brought
Forward
Reductions Sign
33
S or X

Reductions field contains zeros,
otherwise it will be a negative (-)
sign.
Amount Brought
Forward Other
Deductions
34
For future use (presently zero

filled)
Amount Brought
Forward Other
Deductions Sign
43
For future use (presently a space)
Reserved for MOH

Use
44
36
Spaces
Field Name
Field Description
NOTE: Priority of Deductions
1.
2.
3.
6 - 15
Claim adjustments
Advances
Reductions
6.5
Accounting Transaction Record

Occurs Once for Each Accounting Transaction
Field Name
Field
Start
Position
Field
Length
Format
Always HR
Record Type
Always 7
Transaction Code
Cheque Indicator
Transaction Date
Transaction Amount
15
Transaction Amount
Sign
23
S or X
Field Description
10 Advance
20 Reduction
30 Unused
40 Advance repayment
50 Accounting adjustment
70 Attachments
Refer to Section 6.6 Accounting
Transactions for Record Type 7
Ministry use:
M Manual Cheque issued
C Computer Cheque issued
I Interim payment Cheque/ Direct
Bank Deposit issued
Date of transaction created
A space if Transaction Amount is

positive
Negative (-) sign if Transaction
Amount is negative
Transaction Message
24
50
S or X
Description of transaction
Reserved for
MOH Use
74
Spaces
6 - 16
6.5
Message Facility Record Health Reconciliation

May be present, if present may occur up to 500 times.
Field Name
Field
Start
Position
Field
Length
Format
Always HR
Record Type
Always 8
Message Text
70
Message (contains upper case

and lower case)
Reserved for
MOH Use
74
Spaces
Field Description
NOTE: If there is more than one
message, they will be

separated by a record
containing asterisks (e.g.,
position 4 to 73 of one
record type 8).
6 - 17
6.6 Accounting Transactions for Record Type 7

Transaction Code 10 - Advance is created when:
A health care provider receives an interim payment (cheque or direct bank deposit).
A health care provider receives a manual or computer issued advance (cheque only).
A Transaction Code 10 - Advance is created with the amount of the interim payment/advance. This
amount is always negative and is deducted from the total remittance payable. If it exceeds the total
remittance payable it is carried forward to the next months remittance as a Record Type 6 or part of
it (Amount Brought Forward - Advances) with a negative value.
Transaction Code 20 - Reduction is created when:
A debit is required for claim items purged by the system.
The Private Medical Laboratory Utilization Discount System requires a deduction.
Automated estimated payment(s) are recovered.
Other deductions as requested by various ministry branches.
A Transaction Code 20 - Reduction is created with the amount requested to be deducted. This
amount is always negative and is deducted from the total remittance payable. If the reduction
exceeds the total remittance payable, it is carried forward to the next months remittance as a Record
Type 6 or part of it (Amount Brought Forward - Reductions) with a negative value.
Transaction Code 40 - Advance Repayment is created when:
An interim payment is cancelled before the payment is made.
A providers personal cheque is received as repayment on a previously issued advance or

interim payment or unrecovered part thereof.
A Transaction Code 40 - Advance Repayment is created with the amount of the interim payment/
repayment. This amount is always positive and is added to the total remittance payable. Transaction
Code 40 is also used to identify RMB accounting transactions.
Transaction Code 50 - Accounting Adjustment is created when:
A bulk retroactive adjustment payment is processed (e.g., new Schedule of Benefits).
Claims submitted prior to cut-off do not get fully processed for payment (e.g., Automated
Estimated Payments).
A providers personal cheque is received as a payment to offset a negative remittance advice.
A Transaction Code 50 accounting adjustment is created with the retroactive/repayment amount.

This amount is always positive and is added to the total remittance payable.
Transaction Code 70 - Attachments is created when:
There is a legal obligation to deduct and redirect monies to a third party.
6 - 18
6.7 Remittance Advice Explanatory Codes

Eligibility
EA Service date is not within an eligible period - services provided on or after the 20th
of this month will not be paid unless eligibility status changes
EV Check health card for current version
EF
Incorrect version code - services provided on or after the 20th of this month will not
be paid unless the current version code is provided
E1
Service date is prior to start of eligibility
E2
Incorrect version code for service date
E4
Service date is after the eligibility termination date
E5
Service date is not within an eligible period
J7
Claim submitted six months after service date
GF Coverage lapsed - bill patient for future claims

General
30
This service is not a benefit of the ministry
32
Ministry records show that this service has already been claimed for payment
to the patient
35
Ministry records show this service rendered by you has been claimed previously
36
Ministry records show this service has been rendered by another

practitioner, group, lab
37
Effective April, 1993 the listed benefit for this code is 0 LMS units
40
This service or related service allowed only once for same patient
48
Paid as submitted - clinical records may be requested for verification purposes
49
Paid according to the average fee for this service - independent consideration will be given if
clinical records/operative reports are presented
50
Fee allowed according to the appropriate item in the current ministry Schedule of Benefits
for physician services
51
Fee Schedule Code changed in accordance with Schedule of Benefits
52
Fee for service assessed by medical consultant
53
Fee allowed according to appropriate item in a previous ministry Schedule of Benefits
54
Interim payment claim under review
6 - 19

6.7
Remittance Advice Explanatory Codes (continued)
General (continued)
55
This deduction is an adjustment on an earlier account
56
Claim under review
57
This payment is an adjustment on an earlier account
58
Claimed by another physician within your group
59
Health Care Providers notification - WCB claims
61
OOC claim paid at greater than $9999.99 (prior approval on file)
65
Service included in approved hospital payment
68
Hospital accommodation paid at standard ward rate
69
Elective services paid at 75% of insured costs
70
OHIP records show corresponding procedure(s)/visit(s) on this day claimed previously
80
Technical fee adjustment for hospitals and IHFs
AP This payment is in accordance with legislation-if you disagree with the payment
you may appeal
DM Paid/disallowed in accordance with ministry policy regarding emergency department
equivalent
EB Additional payment for the claim shown
I2
Service is globally funded
J3
Approved for stale date processing
Q8
Laboratory not licensed to perform this test on date of service
SR
Fee reduced based on ministry utilization adjustment - contact your physician/

practitioner
TH Fee reduced per ministry Payment Policy - contact your physician
6 - 20

6.7
Consultations
C1
Allowed as repeat/limited consultation/midwife-requested emergency assessment
C2
Allowed at reassessment fee
C3
Allowed at minor assessment fee
C4
Consultation not allowed with this service - paid as assessment
C5
Allowed as multiple systems assessment
C6
Allowed as Type 2 Admission Assessment
C7
An admission assessment C003A or general re-assessment C004A may not be claimed

by any physician within 30 days following a pre-dental/pre-operative assessment
Critical Care
G1
Other critical/comprehensive care already paid
Diagnostic and Therapeutic Procedures

D1
Allowed as repeat procedure; initial procedure previously claimed
D2
Additional procedures allowed at 50%
D3
Not allowed in addition to visit fee
D4
Procedure allowed at 50% with visit
D5
Procedure already allowed - visit fee adjusted
D6
Limit of payment for this procedure reached
D7
Not allowed in addition to other procedure
D8
Allowed with specific procedures only
D9
Not allowed to a hospital department
DA Maximum for this procedure reached - paid as repeat/chronic procedure

DB Other dialysis procedure already paid
DC Procedure paid previously not allowed in addition to this procedure - fee adjusted
to pay the difference
DD Not allowed as diagnostic code is unrelated to original major eye exam
DE Laboratory tests already paid - visit fee adjusted
DG Diagnostic/miscellaneous services for hospital patients are payable on a fee-for-service basis
- included in hospital global budget
DH Ventilatory support allowed with Haemodialysis
6 - 21

6.7
Diagnostic and Therapeutic Procedures (continued)
DL Allowed as laboratory test in private office

DM Paid/disallowed in accordance with MOH policy regarding an Emergency Department
Equivalent
DN Allowed as pudendal block in addition to procedure as per stated policy
DP
Procedure paid previously allowed at 50% in addition to this procedure - fee adjusted
to pay the difference
DV Service is included in Monthly Management Fee for Long-Term Care Patients

Fractures
F1
Additional fractures/dislocations allowed at 85%
F2
Allowed in accordance with transferred care
F3
Previous attempted reductions (open or closed) allowed at 85%
F5
Two weeks aftercare included in fracture fee
F6
Allowed as Minor/Partial Assessment
Hospital Visits
H1
Admission assessment or ER assessment already paid
H2
Allowed as subsequent visit; initial visit previously claimed
H3
Maximum fee allowed per week after 5th week
H4
Maximum fee allowed per week after 6th week to paediatricians
H5
Maximum fee allowed per month after 13th week
H6
Allowed as supportive or concurrent care
H7
Allowed as chronic care
H8
Hospital number and/or admission date required for in-hospital service
H9
Concurrent care already claimed by another doctor
HA Admission assessment claimed by another physician - hospital visit fee applied

HF Concurrent or Supportive Care already claimed in period
6 - 22
6.7
Laboratory
L1
This service paid to another laboratory
L2
Not allowed to non-medical laboratory director
L3
Not allowed in addition to this laboratory procedure
L4
Not allowed to attending physicians
L5
Not allowed in addition to other procedure paid to another laboratory
L6
Procedure paid previously to another laboratory, not allowed in addition to this

procedure - fee adjusted to pay difference
L7
Not allowed - referred specimen
L8
Not to be claimed with prenatal/fetal assessment as of July 1, 1993
L9
Laboratory services for hospital in-patients are not payable on a fee-for-service

basis-included in the hospital global budget
LS
Paid in accordance to Special Lab Agreement
Paediatric Care
P2
Maximum fee allowed for low-birth weight care
P3
Maximum fee allowed for newborn care
P4
Fee for newborn/low-birth weight care is not billable with neonatal intensive care
P5
Over-age for paediatric rates of payment
P6
Over-age for well baby care
Obstetrics
O1
Fee for obstetric care apportioned
O2
Previous prenatal care already claimed
O3
Previous prenatal care already claimed by another doctor
O4
Office visits relating to pregnancy and claimed prior to delivery included in obstetric fee
O5
Not allowed in addition to delivery
O6
Medical induction/stimulation of labour allowed once per pregnancy
O7
Allowed as subsequent prenatal visit. Initial prenatal visit already claimed
O8
Allowed once per pregnancy
O9
Not allowed in addition to post-natal care
6 - 23

6.7
Office and Home Visits

V1
Allowed as repeat assessment - initial assessment previously claimed
V2
Allowed as extra patient seen in the home
V3
Not allowed in addition to procedural fee
V4
Date of service was not a Saturday, Sunday, or a statutory holiday
V5
Only one oculo-visual assessment (OVA) allowed within a 12-month period for age 19 and
under or 65 and over and one within 24 months for age 20-64
V6
Allowed as minor assessment - initial assessment already claimed
V7
Allowed at medical/specific reassessment fee
V8
This service paid at lower fee as per stated ministry policy
V9
Only one initial office visit allowed within 12-month period
VA Procedure fee reduced. Consultation/visit fees not allowed in addition

VB Additional OVA is allowed once within the second year for patients aged 20-64, following a
periodic OVA
VG Only one geriatric general assessment premium per patient per 12-month period
VM Oculo-visual minor assessment is allowed within 12 consecutive months following a major
eye exam
VP
Allowed with specific visit only
VS
Date of service was a Saturday, Sunday or statutory holiday
VX Compexity Premium not applicable to visit fee

Radiology
X2
G.I. tract includes cine and video tape
X3
G.I. tract includes survey film of abdomen
X4
Only one BMD allowed within a 24 month period for a low risk patient
6 - 24

6.7
Surgical Procedures
S1
Bilateral surgery, one stage, allowed at 85% higher than unilateral
S2
Bilateral surgery, two stage, allowed at 85% higher than unilateral
S3
Second surgical procedure allowed at 85%
S4
Procedure fee reduced when paid with related surgery or anaesthetic
S5
Not allowed in addition to major surgical fee
S6
Allowed as subsequent procedure-initial procedure previously claimed
S7
Normal pre-operative and post-operative care included in surgical fee
SA Surgical procedure allowed at consultation fee

SB
Normal pre-operative visit included in surgical fee - visit fee previously

paid-surgical fee adjusted
SC
Not allowed major pre-operative visit already claimed
SD Not allowed-team/assist fee already claimed

SE
Major pre-operative visit previously paid and admission assessment previously

paid - surgery fee reduced by the admission assessment
Dental Services
T1
Fee allowed according to surgery claim
Health Examinations
R1
Only one health exam allowed in a 12-month period
Maxima
M1 Maximum fee allowed or maximum number of services has been reached same/any provider
M2 Maximum allowance for radiographic examination(s) by one or more practitioners
M3 Maximum fee allowed for prenatal care
M4 Maximum fee allowed for these services by one or more practitioners has been reached
M5 Monthly maximum has been reached
M6 Maximum fee allowed for special visit premium - additional patient seen
MC Maximum of 2 patient case conferences has been reached in a 12-month period
MN Maximum number of sessions has been reached
MS Maximum allowable for sleep studies in a 12-month period by one or more physicians has
been reached
MX Maximum of 2 arthroscopy R codes with E595 has been reached
6 - 25

6.7
Reciprocal Medical Billing (RMB)

60
Not a benefit of RMB agreement
RD Duplicate, paid by RMB

Independent Health Facilities (IHF) Explanatory Codes
FF
Additional payment for the claim shown
I2
Service is globally funded
I3
FSC is not on the IHF licence profile for the date specified
I4
Records show this service has been rendered by another practitioner, group or IHF
I5
Service is globally funded and FSC is not on IHF licence profile
Inquiries
Inquiries regarding overpayments or underpayments should be made within one month of the
Remittance Advice on which the payment appears and must be made and resolved within six
months from the service date for any adjustments to payments to occur. Inquiries should be
submitted on a Remittance Advice Inquiry (form 918-84).
Resubmission of Outstanding Claims

Claims outstanding for two payment cycles after submission should be resubmitted if payment has
not been reported on the Remittance Advice; however, claims should be submitted as soon as
possible after the service is rendered because this does not apply to claims where resubmission after
two payment cycles would exceed the time limits for submitting accounts as per regulatory
requirements (no late than six months after the service is rendered).
6 - 26
7. REJECTION CONDITIONS
7.1
Correction of Errors ........................................................................................... 7 - 1
7.2
Rejection Categories .......................................................................................... 7 - 1
7.3
Error Report Explanatory Codes...................................................................... 7 - 20
7.4
Error Report Rejection Conditions .................................................................. 7 - 21
7. Rejection Conditions
7.1 Correction of Errors
An entire batch or file may be rejected; consequently, it is recommended that batches be
maintained at a manageable size (i.e., batches should not exceed 500 claims). The originator will
be advised by telephone or by receiving a Claim Batch Edit Report through the mail that the
rejected files or batches must be re-submitted.
Rejected individual claims/items to be corrected by the health care provider will appear on an
Error Report with the appropriate error code(s). Once corrected, the claims may be resubmitted
on a subsequent MRI file. In some cases, a ministry office will contact an originator to request
clarification of some aspect of a claim in order to facilitate assessment.
7.2 Rejection Categories

Claims data in machine readable form may be subject to rejection by the ministry at
three levels:
1.0
Rejection of entire file submission
2.0
Rejection of batch within a file
3.0
Rejection of a claim within a batch
Warning messages will be issued when the fields designated as fillers are not spaces.
1.0 Rejection of Entire Submission
The entire unprocessed file will be returned to the originator if any of the following
conditions exist:
1.1
Not an acceptable media type
1.2
Not readable
1.3
First record in the file is not a Batch Header Record
1.4
Record count on the identification label must correspond to actual records within the
file (3490 cartridge only)
1.5
Not standard label (3490 cartridge only)
1.6
Data records not 79 bytes
1.7
Record too long (EDT only)
1.8
Record too short (EDT only)
7-1

7.2
Rejection Categories (continued)

Changes are required to billing software in order to receive and process the following EDT
claims output files and because the user may be accessing the Remittance Advice (RA) from
a different drive. The following are the technical specifications for each EDT claim output.
EDT File Reject Message

The Claim File Reject Message is sent to the EDT user ID who submitted the file, only if the
entire claims file is rejected. This report identifies the file rejected and the reasons for rejection.
File reject messages are sent with a file subject of Mail File Reject. These messages have a
filename in the following format:
X
Month
Example:
Field 1
Field 2
Field 3
Field 4
File Number
Sequence Number
XA000001.123
X is a constant used to identify the EDT File Reject Message

Sequential six-digit file number that indicates the position of
the file sending container (e.g., 000001)
Three digit sequence number that indicates the container the file
was delivered in (e.g., 123)
The File Reject Message consists of two record types of 118 characters each: M01 Message
Record 1 and M02 Message Record 2.
7-2

7.2
Reject Message Record 1 (MO1) EDT Claims File

Occurs once per message
Field Name
Field
Start
Position
Field
Length
Format
01
Always M
Record Identifier
02
Always 01
Message Reason
20
Reason for file reject
Invalid Record
Length
24
05
Actual record length submitted
Message Type
29
03
Always ??? to indicate that the

first record on the file was not an
HEB record
Reserved for
MOH Use
32
01
Spaces
Filler
33
07
Always RECORD=
Record Image
40
37
First 37 characters of the first

record in the rejected claims file
Reserved for
MOH Use
77
42
Spaces
7-3
Field Description

7.2
Reject Message Record 2 (MO2) EDT Claims File

Field Name
Field
Start
Position
Field
Length
Format
Always M
Record Identifier
Always 02
Filler
Always FILE:
Provider File Name
12
The file name used to submit the

file
Filler
21
Always DATE:
Mail File Date
26
Date file was uploaded to the

EDT service, in format HHMMSS
Filler
34
Always RECORD=
Mail File Time
39
First 37 characters of the first

record in the rejected claims file
Filler
45
Always PDATE:
Process Date
51
Date file was processed by MOH

in format YYYYMMDD
Reserved for
MOH Use
59
60
Spaces
7-4
Field Description

7.2
Batch Edit Report Record EDT Claims File

Field Name
Field
Start
Position
Field
Length
Format
Always HB
Record Identifier
Always 1
Tech. Spec Release

Identifier
Always V03
Batch Number
A number assigned by ministry
Operator Number
12
From batch header record:
Batch Create Date
18
From batch header record format
Field Description
YYYYMMDD
Batch Sequence
Number
26
From batch header record
Micro Start
30
11
Assigned by ministry: identifies

the first record in a batch, blank
if batch rejected
Micro End
41
Assigned by ministry: identifies

the last record in a batch, blank if
batch rejected
Micro Type
46
Always HCP/WCB or RMB
Group Number
53
Provider Number
57
7-5

7.2
2.0 Rejection of a Batch

Batches will be rejected to the Batch Edit Report if any of the following error conditions occur:
FIRST REC ON FILE NOT BATCH HDR
INVALID DIST CODE ON BATCH HDR
NO CLAIMS ENCOUNTERED ON FILE
CLM HDR1 DOES NOT FOLLOW BATCH HEADER
TRAILER RECORD MISSING
BATCH HEADER MISSING
CLM HDR2 REC NOT AFTER REC TYPE H
TRANSACTION IDENTIFIER MUST BE HE
RECORD IDENTIFIER MUST BE B, H, R, T, E
INVALID COUNTS IN TRAILER RECORD
GROUP# MISSING OR NOT ZEROS
PROVIDER# MISSING
GROUP/PROVIDER# BOTH MISSING OR ZEROS
CREATION DATE INVALID OR NOT YYYYMMDD
GROUP/PROVIDER NOT APPROVED FOR MRI
GROUP/PROVIDER OPERATOR NUMBER INVALID
ITEM REC NOT AFTER REC TYPE H, R OR T
SOLO PROVIDER NOT APPROVED FOR MRI
CLM HDR1 NOT AFTER REC TYPE B, OR T
INVALID CREATION DATE..NOT NUMERIC
TRAILER REC NOT AFTER REC TYPE T
CREATION DATE>SYSTEM DATE
GROUP/PROVIDER NOT APPROVED FOR EDT
UNSUPPORTED TECH SPEC REL. IDENTIFIER
NOTE: Whenever a large number of claims are submitted in a single batch there is the
possibility that the entire submission may reject due to any of the reasons listed above.
We recommend that you attempt to maintain the batch input to a manageable size
(e.g., no more than 500 claims per batch). This claim limit does not apply to EDT.
7-6

7.2
Claims Batch Edit Report

The Claims Batch Edit Report is sent to the EDT user ID specified by the provider at the time of
registration in Part C of the Application for GONet EDT Service. This report acknowledges
receipt of each batch in a claims file and notes if the batch was accepted or rejected.
Claims Batch Edit Reports are sent with a file subject of Claims Batch Acknowledgement. These
messages have a filename in the following format.
B
Month Code
Example:
Field 1
Field 2
Field 3
Field 4
File Number
Sequence Number
BA00001.123
B is a constant used to identify the EDT Claims Batch Edit Report

Sequential five-digit batch control number assigned by the ministry
(e.g., 00001)
7-7

7.2
Batch Edit Report Record EDT Claims Batch

Consists of One Record Type of 132 Characters
Field
Start
Position
Field
Length
Forma
t
Number of Claims
63
Total number of claims in the batch as

calculated by the ministry see Note 1
Number of Records
68
Total number of records in the batch

as calculated by the ministry
Batch Process Date
74
Date batch was processed by MOH

format YYYYMMDD
Edit Message
82
40
BATCH TOTALS left justified in the
Field Name
Field Description
field to indicate an accepted batch or

blank if a sub-total line or R at
position 40 to indicate a rejected
batch, preceded by a reason for the
batch rejection see Note 1 and
Note 3
Reserved for
MOH Use
122
11
Spaces
NOTE 1
Batch edit reports for accepted batches which

contain both HCP/WCP and RMB claims will
show three lines:
- one line with HCP/WCB totals
- one line with RMB totals
- one line with batch totals
NOTE 2
Record count will be zeros if it is a sub-total

record.
NOTE 3
When a batch has an error, two or more

records will be produced. One record for each
error encountered will indicate an error
message and the claim and record counts
pointing to the error position within the batch.
The last record will indicate BATCH TOTALS
with a count of the total claims and total
records within the batch.
7-8

7.2
3.0 Rejection of a Claim

Claims within a batch will be rejected to the Claims Error Report for any of the following
reasons:
3.1
Missing/invalid data as per the field description specified in this manual (error code(s)
prefixed with V)
3.2
Ineligible patient/health care provider data (error code(s) prefixed with E)
3.3
Missing/invalid data as specified in the Schedules of Benefit (error code(s)

prefixed with A)
NOTE: Once corrected, these claims may be resubmitted for payment on a subsequent file.
Corrected claims must be submitted within six months from the date of service.
Claims Error Report

The Claims Error Report is sent to the user ID specified by the provider at the time of
application. This report lists rejected claims, with the appropriate error codes, for correction.
These claims are deleted from the ministrys system and must be corrected and resubmitted in
order to be considered for payment.
Claim Error Reports will be sent with a file subject of Claims Error Report. These messages will
have a filename in the following format.
E
Month Code
Example:
Field 1
Field 2
Field 3
Field 4
Provider, Group or Operator Number
Sequence Number
EA123456.123 or EA1234.123
E is a constant used to identify the EDT Claims Error Report

Health care providers solo provider numbers or registered group
(e.g., 123456 or 1234)
7-9

7.2
The EDT Claims Error Report consists of 6 record types of 79 characters:

HX1
HXH
HXR
HXT
HX8
HX9
Group/Provider Header Record

Claims Header 1 Record
Claims Header 2 Record (RMB claims only)
Claim Item Record
Explan Code Message Record (optional)
Group/Provider Trailer Record
NOTE:
Typically there is one HX1 record per individual solo provider or one HX1 for each member
of a group. The HX1 record will precede one or more rejected claim records for that
individual. However, if within a group of rejected claims for a particular provider the
SPECIALTY CODE changes, then another HX1 record is created to show the different
specialty code.
HXH records will be created for each claim. HXH and HXR records will be created for
RMB claims.
HXT records will be created for each item within the claim. The error report explanatory
code will be added to the HXT record and HX8 records will carry the explanatory code
description. From one to four HX8 message records will be present if there is an
explanatory code on the item level record.
There will only be one HX9 (trailer) record created for each unique group/provider number
that appears in the file. If a provider has rejected claims under two specialties, even though
there will be two HX1 records (as noted above), only one HX9 record will be produced.
7 - 10

7.2
Error Report Header Record (HX1) (EDT)

Field Name
Field
Start
Position
Field
Length
Format
Always HX
Record Identifier
Always 1
Tech. Spec
Release Identifier
Always V03
MOH Office Code
From batch header
Reserved for
MOH Use
10
Spaces
Operator Number
18
From batch header
Group Number
24
From batch header
Provider Number
28
From batch header
Specialty Code
34
From batch header
Station Number
36
Ministry assigned
Claim Process Date
39
Date claim was processed
Reserved for
MOH Use
47
33
Spaces
7 - 11
Field Description

7.2
Error Report Claim Header 1 Record (HXH) (EDT)

Field Name
Field
Start
Position
Field
Length
Format
Always HX
Record Identifier
Always H
Health Number
10
From claim header
Version Code
14
From claim header
Patient Birthdate
16
From claim header
Accounting Number
24
From claim header
Payment Program
32
From claim header
Payee
35
From claim header
Referring
Provider Number
36
From claim header
Facility Number
42
From claim header
Patient
Admission Date
46
From claim header
Referring
Lab Licence
54
From claim header
Location Code
58
From claim header
Reserved for
MOH Use
62
Spaces
Field Description
continued . . .
7 - 12

7.2
Error Report Claim Header 1 Record (HXH)(EDT)

Field
Start
Position
Field
Length
Format
Error Code 1
65
Refer to error code list
Error Code 2
68
Error Code 3
71
Error Code 4
74
Error Code 5
77
Field Name
7 - 13
Field Description

7.2
Error Report Claim Header 2 Record (HXR) (EDT)

RMB Claims Only Occurs Once Per Each RMB Claim
Field Name
Field
Start
Position
Field
Length
Format
Always HX
Record Identifier
Always R
Registration Number
12
From claim header 2
Patients Last Name
16
From claim header 2
Patients First Name
25
From claim header 2
Patient Sex
30
From claim header 2
Province Code
31
From claim header 2
Reserved for
MOH Use
33
32
Spaces
Error Code 1
65
Error Code 2
68
Error Code 3
71
Error Code 4
74
Error Code 5
77
7 - 14
Field Description

7.2
Error Report Item Record (HXT) (EDT)

Multiple Records Occurs Once for Each Item in a Claim
Field Name
Field
Start
Position
Field
Length
Format
Always HX
Record Identifier
Always T
Service Code
From claim item record
Reserved for
MOH Use
Spaces
Fee Submitted
11
Number of Services
17
Service Date
19
Diagnostic Code
27
Reserved for
MOH Use
31
32
Spaces
Explan Code
63
EDT error report explanation
Field Description
code
Error Code 1
65
Error Code 2
68
Error Code 3
71
Error Code 4
74
Error Code 5
77
7 - 15

7.2
Error Report Explanation Code Message Record

(HX8) (EDT)
Optional Occurs 1 to 4 Times Per Claim Item
Field Name
Field
Start
Position
Field
Length
Format
Always HX
Record Identifier
Always 8
Explan Code
Error report explanatory code
Explan Description
55
Explanatory code description
Reserved for
MOH Use
61
19
Spaces
7 - 16
Field Description

7.2
Error Report Trailer Record (HX9) (EDT)

Occurs Once Per File or Once Per Provider for Groups
Field Name
Field
Start
Position
Field
Length
Format
Always HX
Record Identifier
Always 9
Header 1 Count
Count of HXH records
Header 2 Count
11
Count of HXR records
Item Count
18
Count of HXT records
Message Count
25
Count of HX8 records
Reserved for
MOH Use
32
48
Spaces
7 - 17
Field Description

7.2
EDT Error Report Samples for Solo Providers

The following sample shows two rejected claims for the same provider. The first claim has two
items. The second claim is an RMB claim that has one item.
HX1
HXH Claim Header 1

HXT Claim Item
HX8
Explan Code Message Record
HX8
HXT Claim Item

HX8
HXH Claim Header 1

HXR Claim Header 2
HXT Claim Item
HX8
HX8
HX8
HX8
HX9
7 - 18

7.2
EDT Error Report Samples for Group Providers

The following sample shows three rejected claims for two different providers. The first provider
has one claim that has two items. The second provider has an RMB claim with one item under
one specialty and a second claim with one item under another specialty.
HX1
HXH Claim Header 1

HXT Claim Item
HX8
HX8
HXT Claim Item

HX8
HXH Claim Header 1

HXR Claim Header 2
HXT Claim Item
HX8
HX8
HX8
HX8
HX1
Group/Provider Header Record (change in specialty)
HXH Claim Header 1

HXT Claim Item
HX8
HX9
Group/Provider Trailer Record
7 - 19
7.3 Error Report Explanatory Codes

Explanatory Codes/Messages for Use on Re-Routed MRI Claims
The following explanatory codes/messages are used for routing internally rejected MRI claims to
the Providers Error Report.
Explanatory
Code
Message to Error Report
10
Resubmit as RMB claim
11
Bill patient or Quebec medicare
12
Advise patient to contact the ministry re: eligibility/card status
13
Service date is prior to newborns date of birth
14
Fee billed low - check for current SOB fee
15
No. of services exceed maximum allowed
16
Cannot be claimed alone/service date mismatch
17
E409/E410 N/A - resubmit with appropriate assist/anaesthetic
premium codes
18
Resubmit with manual review indicator and provide supporting

documentation for two assistants
19
Resubmit with manual review indicator and forward copy of OP Report
20
Resubmit with manual review documentation
21
Records indicate patient deceased - clarify or confirm
22
Code submitted requires prior approval
23
Hospital visits claimed by more than one physician - clarify role in

patients care
24
Claims appearing on previous RAs as over/under payments should not be

resubmitted - use inquiry form for payment adjustment requests
25
Incomplete newborn registration - have parent/guardian contact the

ministry
26
27
28
One house call assessment (A901) allowed per visit - resubmit claim with
appropriate service code
This duplicate submission is being returned - original submission
currently on file pending medical consultant adjudication
Resubmit with manual review indicator with written explanation for
detention, total time spent with patient including consultation/assessment
indicated
7 - 20
7.4 Error Report Rejection Conditions

General
The following error codes/rejection conditions will be reported on the Claims

Error Report.
Error
Reason(s) For Rejection
AC4
A valid Referring/Requisitioning Health Care Provider number must be present

for this service code
The fee schedule code is C813, C815 and the referral number is not in the
Midwife range (700000-722899)
Referring number is 722900-744292 (Nurse Practitioner) and the billing
provider is not a lab (5000 series) and the FSCs are not on the following table:
L005
L055
L148
L215
L253
L319
L377
L417
L482
L625
L634
L653
L691
L018
L067
L157
L221
L254
L321
L393
L418
L490
L626
L640
L654
L710
L030
L093
L181
L222
L306
L324
L395
L419
L493
L627
L641
L655
L713
L031
L107
L191
L223
L309
L329
L396
L445
L500
L628
L643
L667
L716
L040
L111
L194
L226
L311
L341
L397
L452
L544
L629
L650
L668
L817
L045
L117
L204
L243
L315
L345
L398
L462
L622
L630
L651
L679
L842
L053
L139
L208
L252
L318
L372
L399
L481
L624
L631
L652
L683
Acceptable codes for cardiology services for Nurse Practitioner referrals

(others will reject):
G310
G313
G700
ADM
Emergency equivalent/other visits
AHA
Fee schedule code and time period mismatch
AEV
Visit only allowed
AH5
Admit date mismatch
AH8
In-Patient Admission Date and/or Facility Number are missing and are
required for this service code
AH9
Diagnostic/miscellaneous service for hospital patients is not allowed on a

fee-for service basis - included in the hospital global budget
7 - 21

7.4
Error report Rejection Conditions (continued

General (continued)
Error
A2A
Patient is underage or overage for this service code
A2B
This service is not normally performed for this sex - please check your records
A3E
No such service code for date of service
A3F
No fee exists for this service code on this date of service
A34
Multiple duplicate claims
A4D
Invalid specialty for this service code
EH1
Service date is prior to eligibility start date
EH2
Version code does not match health number version code for service date
EH4
Service date is greater than eligibility end date
EH5
Service date is not within an eligible period
EPA
PCN billing not approved
EPC
Patient not rostered/rostered to another PCN
EPD
Roster/HRR payment discrepancy
EPS
Patient not eligible for program
EQ1
Solo or affiliated Health Care Provider is not registered with the ministry
EQ2
Specialty Code is inactive or not registered on date of service
EQ3
Health Care Provider is registered as OPTED-IN for date of service

Claim submitted as Pay Patient
EQ4
Health Care Provider is registered as OPTED-OUT for date of service.

Claim submitted as Pay Provider
EQ5
Laboratory Licence Number not actively registered with the ministry on this
date of service
EQ6
Referring/Requisitioning Health Care Provider Number is not registered with

the ministry
EQ9
Laboratory Licence Number is not registered with the ministry
EQB
Solo Health Care Provider Number is not actively registered with the ministry
on this date of service
Practitioner number is Midwife (700000-722899) referral only
EQC
Group Number is not registered with the ministry
EQD
Group Number is not actively registered with the ministry on this date of
Service
EQE
Health Care Provider is not registered with the ministry as an affiliate of this
Group on this date of service
7 - 22

7.4
Error Report Rejection Conditions (continued)
General (continued)
Error
EQF
Health Care Provider is not actively registered with the ministry as an affiliate
of this Group on date of service
EQG
Referring Laboratory is not registered with the ministry
EQS
Pract criteria not met
ERF
Referring physician number is currently ineligible for referrals
ESD
APP group affiliation on service date
ESF
A non-encounter service claim submitted by a physician not eligible to bill

FSC
Group number is in the range CAAA CAJ9 and the FSC is not K400A
VJ5
Date of Service is missing/not eight (8) numerics

Month is not in the range 01-12
Day is outside acceptable range for month
Date of Service is greater than ministry system run date
VJ7
Date of Service is six (6) months prior to ministry system run date
V02
Incorrect ministry office code. Missing/not D, E, F, G, J, N, P, R, or U
V05
Date of service is greater than Ministry of Health system run date
V07
Health Care Provider number is missing/not 6 numerics
V08
Specialty code is missing/not 2 numerics

Not a valid specialty code
Specialty Code is 27 and provider number is not 599993
Specialty Code is 90 and provider number is not 991000
Specialty Code is 49, 50, 51, 52, 53, 54, 55, 70, or 71 and Health Care Provider
number does not begin with 4
Specialty Code is 56 and Health Care Provider number does not begin with
80 or 81
Specialty Code is 57 and Health Care Provider number does not begin with
86 or 839985
Specialty Code is 58 and Health Care Provider number does not begin with 87
Specialty Code is 59 and Health Care Provider number does not begin with 88
or 89 or not in range 830000 - 839984
Specialty Code is 80 or 81 and Health Care Provider number does not begin
with 82
V09
Referring Health Care Provider number is not six (6) numerics.

Health Care Provider number is 82XXXX and referring Health Care Provider
number is missing or begins with 4 or 8
Group number begins with 5 or 7 or 8000 - 8599 and referring Health Care
Provider is missing or begins with 4 or 8
7 - 23

7.4
General (continued)
Error
V09
(contd.)
Group number is 6008, 6100, 8600-8999 or 9XXX and referring Health Care
Provider number is missing or begins with 4 or 8 (except for 830000 - 839984,
86XXXX, 88XXXX, 89XXXX)
Referring number is 700000-722899 (MIDWIFE) and
(1) the billing provider is not a LAB (5000 series) and the FSCs are not the
following:
L005, L030, L031, L103, L111, L253, L254, L309, L311, L318, L319,
L329, L341, L372, L393, L396, L399, L417, L418, L431, L453, L471,
L482, L490, L494, L495, L621, L622, L625, L628, L634, L637, L640,
L653, L655, L679, L683, L691, L700, L713, L800, L812
(2) for ultrasounds the FSCs are not the following:
J138/J438
J157/J457
J158/J458
J159/J459
J160/J460
J161/J461
J163/J463
(3) special visit premium codes are not the following:
C990, C991, C992, C993, C994, C995, C996, C997
Referring number is 900100-900600 (Alternate Health Care Professions)
V10
Patients last name is missing/not alphabetic (A - Z)

The first field position is blank
RMB claim only
V12
Patients first name is missing/not alphabetic (A - Z)

The first field position is blank
RMB claim only
V13
Patients date of birth is missing/invalid format

Month not in the range of 01 - 12
Not 8 numerics
Day is outside acceptable range for month
V14
Patient Sex must be 1 (male) or 2 (female)

RMB claim only
V16
Not numeric
Health Care Provider number is 82XXXX and diagnostic code is not four (4)
numerics or is three (3) numerics and not 070, 072, or 880 to 971
Fee schedule code is G423, G424 and diagnostic code is not 360, 371, or 376
7 - 24

7.4
General (continued)
Error
V17
V18
Payee must be P (Provider) or S (Patient)

In-patient admission date is not eight (8) numerics
Month of admission is not in the range of 01-12
Day of admission is outside the acceptable range for month
In-patient admission date is later than ministry system run date
V19
Chiropractic Diagnostic Code is missing/invalid

Chiropractic Diagnostic Code is not C followed by two (2) numerics
Health Care Provider number is 830000 - 839984, 88XXXX or 89XXXX
and diagnostic code not C01-C15, C20-C24, C30-C33, C40-C48, C50-C54
or C60-C62
V20
Service code is A007, patient is over two (2) years old and diagnostic code is
916; or service code is A003 and the patient is under sixteen (16) years old and
the diagnostic code is 917
V21
Diagnostic Code is required for this service
V22
Diagnostic Code is not a valid code
V23
Service code ends in B or C and the number of services is not greater than 01
(refer to Section 5.10 Fee Schedule Code Suffix B/C Exceptions)
V28
Facility Number is not four (4) numerics

Facility Number is not a valid number
V30
FSC/DX Code Combination NAB
V31
Missing all of the following: Group Number, Health Care Provider Number,
Specialty Code, Health Number
V34
Service code begins with V1 and Health Care Provider number does not begin
with 88 or 89, or in range 830000 - 839984 (and the reverse of this condition)
with 86 or is 839985 (and the reverse of this condition)
with 87 (and the reverse of this condition)
with 80, 81, 84, or 85 (and the reverse of this condition)
with 82 (and the reverse of this condition)
Service code is prefixed with T and Health Care Provider number does not
begin with 4, excluding Fee Schedule Codes J99 (and the reverse of this
condition)
Service code begins with H4 and Health Number is not a sessional reference
number
7 - 25

7.4
General (continued)
Error
V36
Check input criteria required for sessional billing
V39
Number of Items exceeds the maximum (99)
V40
Service code is missing

Service code is not in the format ANNNA where:
A is alphabetic (A-Z)
NNN is numeric (001-999)
A is alphabetic (A-C)
V41
Fee Submitted is missing/not six (6) numerics

Fee Submitted is not in the range 000000 - 500000 ($$$$cc)
V42
Number of Services is missing/not two (2) numerics

Number of Services is not in the range 01-99
V47
Fee Submitted is not evenly divisible (to the cent) by the number of services
V51
Invalid location code - must be blank or four numerics - if present, must be valid
based on MOH Residency Code Manual
V62
Invalid service location indicator assigned when a Service Location Indicator

code included with a hospital diagnostic service billing from a participating
hospital physician/group is not one of the four valid SLI codes
V63
Referring Laboratory Number must start with 5 (5###)
V64
Missing service location indicator assigned when a hospital diagnostic service is

billed by a participating hospital physician/group but a service location indicator
code was not included
V65
Missing master number assigned when SLI code HDS, HED, HIP, or HOP is
included with a diagnostic service billing from a participating hospital
physician/group but a master number was not included
V66
Missing admission date assigned when SLI code HIP is included with a
diagnostic service billing from a participating hospital physician/group but an
admission date was not included
V67
Missing master number and admission date assigned when SLI code HIP is
included with a diagnostic service billing from a participating hospital/group but a
master number and admission date were both not included
V68
Incorrect service location indicator assigned when a diagnostic service is billed

from a participating hospital physician/group with a master number and admission
date but the SLI code is not HIP
V70
Date of Service is greater than the file/batch creation date
7 - 26

7.4
Independent Health Facilities (IHF)

Error
A14
Records show this service has been rendered by another practitioner, group or IHF
EF1
IHF number not approved for billing on the date specified
EF2
IHF not licensed or grandfathered to bill FSC on the date specified
EF3
Insured services are excluded from IHF billings
EF4
Provider is not approved to bill IHF fee on date specified
EF5
IHF practitioner 991000 is not allowed to bill insured services
EF7
Referring physician number is required for the IHF facility fee billed
EF8
I Service codes are exclusive to IHFs
EF9
Mobile site number required
Reciprocal Medical Billing (RMB)

Error
R01
Missing registration number
R02
Number of digits disagrees with the corresponding Province Code (refer to

Section 5.14 Province Codes and Numbering)
R03
Province Code missing

Not a valid Province Code (refer to Section 5.14 Province Codes and Numbering)
R04
Fee Schedule Code excluded from RMB
R05
ON (Ontario Province Code) not valid for RMB
R06
Wrong Health Care Provider for RMB (begins with 3, 4, 8, or 9)
R07
Invalid pay type for RMB (must be P)
R08
Invalid referral number (applies to Outaouais Region, Quebec only)

Not 7 numerics
R09
Claim Header-2 is missing and the payment program is RMB
7 - 27
7.4 Error Report Rejection Conditions (continued)
Workers Compensation Board (WCB)

Error
VW1
Service not valid for WCB
Health Number
Error
VHB
A non-encounter service claim submitted with a Health Number
VHO
Claim Header-2 present on MRI claim submitted with Health Number in

Claim Header-1
VH1
Health Number is missing/invalid (does not pass MOD 10 Check routine)

Health Number is a number reserved for testing purposes (refer to
Section 3.1 Acceptance Testing)
VH2
Health Number is not present (Payment program is HCP or WCB)
VH3
The payment program is missing or is not equal to HCP, RMB, WCB
VH4
Invalid Version Code
VH5
Claim Header-2 is missing (service is before January 1, 1991 and Payment

Program is HCP)
VH8
Date of birth does not match the Health Number submitted
VH9
Health Number is not registered with ministry
NOTE: These error codes are subject to change.
7 - 28
8. HEALTH CARD MAGNETIC

STRIPE SPECIFICATIONS
8.1 Health Card Types .............................................................................................8 1
8.2
Magnetic Stripe Specifications ..........................................................................8 2
8. Health Card Magnetic Stripe Specifications

8.1 Health Card Types
Health Number
Version code on
replacement cards only
Name
OHIP number
Expiry date of
coverage (month/year)
not on all cards
Health 65 Indicator
signifies eligibility for
Ontario Drug Benefit
(available only in
Ontario)
Date of Birth
Sex
Cards must be signed. Red cards are signed on the back while the photo card is signed on
the front.
8-1
8.2 Magnetic Stripe Specifications

Recording density 210 bpi
7 bits per character, 79 alphanumeric characters
Track I
Field
Field Name
Size
Comments/Values
Start Sentinel
Value = %
Format Code
Value = b
Issuer Identification
Value = 610054"
Health Number
10
Field Separator
Value = ^
Name
26
As per ISO standards. Separated by /
Field Separator
Value = ^
Expiry Date
YYMM or zero filled
Interchange Code
10
Service Code
Value = 99"
11
Sex
1 = Male 2 = Female
12
Date of Birth
YYYYMMDD
13
Card Version Number
XX (may be blank)
14
First Name-Short
First 5 characters of first or middle name
15
Issue Date
YYMMDD
16
Language Preference
01=END 02=FR
17
End Sentinel
Value = ?
18
Longitudinal Redundancy Check

(Parity)
As per ISO standards
8-2

8.2
Magnetic Stripe Specifications (continued)
Track II
Field

5 bits per character, 40 numeric characters
Field Name
Size
Comments/Values
Start Sentinel
Value = ;
Value = 610054"
Health Number
10
Field Separator
Value = =
Expiry Date
YYMM or zero filled
Interchange Code
Value = 7"
Service Code
Value = 99
Filler
Value = 0000"
Card Type
1 = REG 2 = 65
10
OHIP Number
Number or 00000000"
11
12
End Sentinel
Longitudinal Redundancy Check
(Parity)
1
1
Value = ?
For the Expiry Date on Track I & II and the Issue Date on Track I the year remains as a two
digit character:
if the year is 30 or less, then the century is 20"
if the year is greater than 30, then the century is 19"
Example:
Expiry Date
Expiry Date
Expiry Date
Issue Date
Issue Date
Issue Date
3001
2901
3101
000101
980101
890101
=
=
=
=
=
=
203001
202901
193101
20000101
19980101
19890101
8-3
Magnetic Stripe Specifications (continued)
Track III
Field
1
2
3
4
5
6
7
8

5 bits per 980 character, 107 numeric characters
Field Name
Size
Start Sentinel
Format Code
Health Number
Field Separator
Filler
End Sentinel
Longitudinal redundancy Check
(Parity)
1
2
6
10
1
85
1
1
NOTE: Track III is reserved for possible future use.
8-4
Comments/Values
Value = ;
Value = 90"
Value = 610054"
Value = =
Value = 0"
Value = ?
9. OVERNIGHT BATCH
ELIGIBILITY CHECKING
9.1 Overview........................................................................................................... 9 1
9. Overnight Batch Eligibility Checking (OBEC)

9.1 Overview
The OBEC application allows health care providers to identify potential invalid health
cards/version codes before a service is provided. It is designed to supplement the current online
validation systems.
Users access the OBEC application within the EDT service and transfer a file containing health
numbers and version codes. This file is gathered together with files from other users and
forwarded to the ministry. The ministry processes these files against the Registered Persons
Database (RPDB) and eligibility is verified using the health number/version code provided.
Eligibility is checked based on the date the file was submitted. Providers may use this service
as often as they like, ideally they should perform the check the day before giving the service.
OBEC responses are identical to those provided by the ministrys Interactive Voice Response
(IVR) and Health Card Reader (HCR) systems. OBEC does not provide the correct health
number/version codes nor does it guarantee payment.
Refer to:
Electronic Data Transfer Reference Manual
Health Card Validation Reference Manual
Interactive Voice Response Reference Manual
9-1
10. HEALTH CARD VALIDATION

10.1
Overview ........................................................................................................10 1
Health Card Validation
10. Health Card Validation

10.1 Overview
The of Health Card Validation (HCV) System enables hospitals, physicians or other health care
providers to validate a health card when presented at the point of service. The validation
transaction checks the status and validity of the 10-digit health number presented.
Benefits
Validation responses provide decision-making capability at the time of service and allow a
health care provider to:
reduce claim rejects

reduce version code rejects
reduce administrative costs
reduce health care fraud
verify patient data
For more information refer to the Health Card Validation Reference Manual.
10 - 1
11. APPENDICES
11.1
Glossary..........................................................................................................11 1
11.2
Websites ........................................................................................................11 8
Appendices
11. Appendices
11.1
Glossary
Accounting Number
An eight (8) character, alpha-numeric field which may be used by the health care provider or
billing agent for claim identification. If used, this identifier will be reported on the Remittance
Advice (hard copy, magnetic tape or disk medium).
Address
A computer system location identified by a name, number, or code label. The address can be
specified by the user or by a program.
ASCII File
A file that contains data made up of ASCII characters. Each byte in the file contains one
character that conforms to the standard ASCII code. Program source code, DOS batch files,
macros and scripts are written as straight text and stored as ASCII files.
Baud Rate
The speed at which data transfers between two devices, such as between two computers
connected via modem.
Billing Agent
An agent authorized by a health care provider, or a group of health care providers, to prepare
their claims data on machine-readable media for processing by the ministry and/or to reconcile
payment data on machine-readable media provided by the ministry.
Bits Per Second (BPS)
A measurement of data transmission speed.
Carriage Return/Line Feed (3.5" Diskettes)
End of record control characters must be present. The hexadecimal characters 0D convert to
Carriage Return in ASCII. The hexadecimal characters 0A convert to Line Feed in ASCII.
CCITT V.32BIS
A high-speed modulation protocol for computer modems that governs data transmission at
speeds of 14,400 bits per second. A modem that conforms to this standard is downwardly
compatible with V.32 modems, meaning that it can slow down to 9,600 bps to accommodate a
slower modem on the other end of the line.
CCITT V.42BIS
A data-compression protocol for computer modems that speeds transmissions by compressing
data on the sending end and decompressing the data on the reception end. If the data is not
already compressed, gains in effective transmission speeds of up to 400 percent can be realized.
11 - 1
Appendices
Communication Protocol
A list of communications parameters (settings) and standards that govern the transfer of
information among computers using telecommunications. Both computers must have the same
settings and follow the same standards to avoid errors.
Communication Software
A type of software used to establish a connection and exchange data with another computer.
Compressed File
A file that has been reduced in size by converting to a more compact format.
Data Link
A communication published by the Ministry of Health and Long-Term Care to update registered
vendors, billing agents and health care providers about changes in the conditions, procedures or
specifications concerning claims processing in machine readable form.
Datapac
A phone service offered by Bell Canada that provides (for a fee) the communication lines on
which the file transfer data is sent through telephone lines from authorized users to the EDT
computer.
Demodulation
In telecommunications, the process of receiving and transforming an analog signal into its digital
equivalent so that a computer can use the information.
Designated Plan Representative
An official of the Ministry of Health and Long-Term Care.
Device
Any hardware component or peripheral, such as a printer, modem, monitor or mouse that can
receive and/or send data.
Diskette/Cartridge Originator
The name of the facility that actually prepares the machine readable input for transmittal to the
ministry. This facility may be health care provider or a billing agent/service bureau.
Downloading
The process of receiving a file from another computer.
An Ontario government service that allows authorized users to transfer files (via a modem and
telephone line) from their computer to government mainframe computers. The ministry
currently offers two EDT applications: fee-for-service medical claims and Overnight Batch
Eligibility Checking (OBEC) of health cards.
11 - 2
Appendices
ENA
External Network Access
Facility Number
A four (4) digit number assigned by the ministry to identify specific health care facilities,
including hospitals and sites for mobile diagnostic IHF services.
Fee Schedule Code
The codes appearing opposite the description of insured benefits listed in the various Ministry of
Health and Long-Term Care Schedules of Benefits and Facility Fee Schedule. The instructions
pertaining to its use are included in the Preambles of the Schedule of Benefits. Used interchangeably with service code.
File Transfer
The process of using communications to move or transmit a file from one computer to another,
using a protocol which has been agreed upon.
File Transfer Protocol (FTP)
A list of communications parameters (settings) and standards that govern the transfer of
information among computers using telecommunications. Both computers must have the same
settings and follow the same standards to avoid errors.
Government of Ontario Network (GONet)
The interface designed by the Ontario Government that is used to upload and download
(send/receive) files.
Group Numbers
A four (4) digit alpha-numeric ministry registration number assigned to organizations to facilitate
payment consolidation.
Hardware Platform
A computer hardware standard, such as IBM PC-compatible or MacIntosh personal computers.
Devices or programs created for one platform will not run on others.
HCP Claim
A regular in-province medical claim (includes Independent Health Facility claims).
Any provider, group, licensed laboratory, private physiotherapy facility or independent health
facility that is registered with the ministry to provide insured services.
Health Care Provider Number
The six (6) digit Ministry of Health and Long-Term Care registration number assigned to
individual providers, private physiotherapy facilities, laboratory directors and independent health
facility practitioners who are lawfully entitled to provide insured services.
11 - 3
Appendices
Health Codes
The two (2) numerics assigned to a provider depending on area of specialty.
Health Encounters
A health encounter marks the occurrence of a service by a health care provider for a patient.
This service may be billable to the ministry in the format outlined in the MRI specifications
section.
Health Numbers
The unique ten (10) digit individual health identification number assigned by the ministry to
eligible Ontario residents.
Health reconciliation is the Remittance Advice information supplied by the ministry in the
format outlined in the MRO Specifications section, to be reconciled with claims for health
encounters.
Independent Health Facility Number
A four (4) digit alpha-numeric Ministry of Health and Long-Term Care registration number
identifying each Independent Health Facility (IHF).
Independent Health Facility Practitioner Number
A unique six (6) digit number issued by the Ministry of Health and Long-Term Care to identify
persons lawfully entitled to provide insured services or assigned for non-medical operators of
licensed Independent Health Facilities.
The date of admission for in-patients to a health care facility. Previously referred to as hospital
admission date.
Laboratory Director Number
The unique six (6) digit number issued by the Ministry of Health and Long-Term Care to persons
lawfully entitled to provide insured services, or the unique six (6) digit number assigned for nonmedical laboratory directors.
Laboratory Licence Number
Each licensed location of a laboratory facility is registered with the ministry and is assigned a
four (4) digit registration number, which is the same as the licence number issued by the
Laboratory Licensing Branch.
Log Off
The process of terminating a connection with a computer system or peripheral device in an
orderly fashion.
Log On
The process of establishing a connection with, or gaining access to, a computer system or
peripheral device.
11 - 4
Appendices
Mailbox
Users have a mailbox on the EDT service where files are sent from the ministry or other users.
This mailbox can only be accessed by using the authorized ID and password. Files will remain
in the mailbox until they are downloaded, deleted or expired.
Mainframe
A multi-user computer designed to meet the computing needs of a large organization.
Manual Review Indicator
A trigger on a Health Encounter Claim Header-1 Record, used to force review by the ministry of
additional documentation related to the claim.
Medical Consultant
A physician or dentist employed by the Ministry of Health and Long-Term Care to adjudicate
complex or independent consideration (IC) claims, to institute or advise on claims payment
policy, to institute and interpret the Schedule of Benefits and to liaise with health care providers
and the public.
Menu
An on-screen display that lists available command choices.
MNP
Multi-Network Protocol
MOD 10 Check Digit
A program check that validates health numbers.
Modem
A device that allows communication between two computers through telephone lines.
Modulation
The conversion of a digital signal to its analog equivalent, especially for the purposes of
transmitting signals via telecommunications.
Network User Identifier (NUI)
The Datapac NUI is issued by Bell Canada to allow users to access the GONet EDT service.
The NUI is used to track use of the system for billing purposes.
Operator Number
A six (6) digit number assigned by the Ministry of Health and Long-Term Care to uniquely
identify the processing installation used by health care providers for the MRI/MRO interface.
Refer to Billing Agent definition for further details.
Output
A file sent from the ministrys mainframe in response to an input file.
11 - 5
Appendices
Overnight Batch Eligibility Checking (OBEC)

Allows an authorized user to electronically send a formatted file of health numbers/version codes
to the ministry for validation before a health service is provided.
Password
A security tool used to identify authorized users of a computer program or computer network and
to define their privileges, such as: read-only, reading and writing or file copying.
Password Protection
A method of limiting access to a program or a network by requiring you to enter a password.
Payee
Pay Provider (P): A provider who accepts payment for insured services directly from the
ministry (OPTED-IN).
Pay Patient (S): A provider who accepts payment from the patient and submits a claim to the
ministry on the patients behalf (OPTED-OUT).
Payment Program
The program that is responsible for the payment of the claim (e.g., Health Claims Payment
(HCP), Workers Compensation Board (WCB) and Reciprocal Medical Billing (RMB).
Peripheral
A device, such as a printer or disk drive, connected to and controlled by a computer, but external
to the computers central processing unit (CPU).
Private Physiotherapy Facility (Number)
A six (6) digit number assigned by the ministry to a facility which has been registered by the
ministry to lawfully provide insured physiotherapy services.
Prompt
A symbol or phrase that appears on-screen to inform you that the computer is ready to accept
input.
Protocol
A set of standards for exchanging information between two computer systems or two computer
devices.
Province Code
A code that is required for reciprocal claims to identify the province of the patients
registration/address.
Random-Access Memory (RAM)
Read/write memory where work space is set aside for your data, enabling you to modify
(rewrite) as needed until the data is ready for printing or storage on disk.
11 - 6
Appendices
Read Only
Capable of being displayed, but not edited, formatted or otherwise modified.
Reciprocal Medical Billing Claim
A service rendered by an Ontario health care provider to a patient registered with another
provincial health plan.
Referring/Requisitioning Health Care Provider
The six-digit number of the health care provider who is referring a patient to another health care
provider for consultation or who is requisitioning diagnostic services (e.g., laboratory tests).
Registration Number
The equivalent health number of residents registered in provinces other than Ontario.
Report
A printed output that usually is formatted with page numbers and headings.
Script Files
A program written to automate the communications process to allow unattended access when
uploading or downloading. An automated script may include the keystrokes necessary to log on,
upload, download and log off.
Save
To transfer data from the computers random-access memory, where it is liable to erasure, to a
secondary storage medium such as a disk drive.
Security Code Word
A confidential word selected by the user to assist in verifying the user to the ministry.
TCP/IP
Transmission Control Protocol/Internet Protocol
Terminal Emulation/Type
Using a software product, making your computer act as if it were a particular type of terminal in
order to communicate with another computer, such as a mainframe, or the EDT service.
Upload
The process of sending a file to another computer.
User Identification (User ID)
Access to the EDT services is restricted to authorized users with the appropriate ID and
password.
Version Code
A code (two alpha-characters) used to identify new or replacement health cards issued since
September 1994. Prior to that date only replacement cards had a version code consisting of one
or two letters. The original issue red and white cards had a blank version code.
Workers Compensation Board Claim
A claim for a service to which Workers Compensation Board benefits are applicable. This
board is currently referred to as Workplace Safety and Insurance Board.
11 - 7
Appendices
11.2 Websites
Ministry of Health and Long-Term Care
www.health.gov.on.ca
Health Care Professionals

www.health.gov.on.ca/english/providers/providers_mn.html
Health Care Professionals Publications OHIP

www.health.gov.on.ca/english/providers/pub/pub_menus/pub_ohip.html
Schedule of Benefits Physicians Services

www.health.gov.on.ca/english/providers/program/ohip/sob/sob_mn.html
Resource Manual for Physicians

www.health.gov.on.ca/english/providers/pub/ohip/physmanual/physmanual_mn.html
Electronic Data Transfer

www.health.gov.on.ca/english/providers/pub/ohip/edtguide/edt_mn.html
Health Card Validation

www.health.gov.on.ca/english/providers/pub/ohip/ohipvalid_manual/ohipvalid_manual_mn.html
Interactive Voice Response

www.health.gov.on.ca/english/providers/pub/ohip/inter_voiceresp/inter_voiceresp_mn.html
OHIP Bulletins
www.health.gov.on.ca/english/providers/program/ohip/bulletins/bulletin_mn.html
Forms and Applications

www.health.gov.on.ca/english/providers/forms/form_menus/ohip_prof_fm.html
Acts and Regulations

www.e-laws.gov.on.ca
11 - 8

OHIP Technical Specification

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OHIP Technical Specification

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Technical

Technical Specifications Interface to Health Care Systems

Ministry of Health and Long-Term Care

Technical Specifications Interface to Health Care Systems

Media Types .........................................................................................................................4 - 1

Machine Readable Input Specifications

Initial Claims File.................................................................................................................3 - 1

Processing Schedules ...........................................................................................................2 - 1

File Naming convention .......................................................................................................5 - 1

Machine Readable Output Specifications

Remittance Advice ...............................................................................................................6 - 1

Technical Specifications Interface to Health Care Systems

Health Card Magnetic Stripe Specifications

Overnight Batch Eligibility Checking (OBEC)

10. Health Card Validation

Office Locations and Contact Numbers..............................................................1 - 2

Technical Specifications Interface to Health Care Systems

Technical Specifications Interface to Health Care Systems

1.2 Office Locations and Contact Numbers

119 King Street West, 10th Floor

1055 Princess Street, Ste. 401

217 York Street, 5th Floor

201 City Centre Drive, Ste. 300

419 King Street West

75 Albert Street, 7th Floor

199 Larch Street, Ste. 801

435 James Street South, Ste 113

47 Sheppard Ave. East, Ste. 417

Processing Schedules ......................................................................................... 2 - 1

Technical Specifications Interface to Health Care Systems

2.2 Shipping Requirements

Technical Specifications Interface to Health Care Systems

Name of the Health Care Provider, Group or Billing Agent

Number of records submitted incorrect record counts will result in rejection of

Serial number (originators identification: 3 alphabetics assigned by the ministry,

Technical Specifications Interface to Health Care Systems

3.5" Diskette Labels

Health Care Provider or Group Name

Diskette Identification - name of the MS-DOS or Macintosh file that appears on

Phone number of contact person (in case of file/batch rejection)

Number of claims submitted

Number of records submitted

Date of submission to the ministry

Initial Claims File .............................................................................................. 3 - 1

Patient Set-Up File............................................................................................. 3 - 2

Technical Specifications Interface to Health Care Systems

Technical Specifications Interface to Health Care Systems

3.2 Patient Set-Up File

Header Record Patient Set-Up File

Reserved for MOH

Technical Specifications Interface to Health Care Systems

Patient Set-Up File (continued)

Detail Record Patient Set-Up File

Patient First Name

Version Code Match

Patient Birth Date

Y = yes N = no (refer to Note)

The Patient Set-up File identifies the

Technical Specifications Interface to Health Care Systems

Logical Record Length = 79 characters

Soft Sectored Only

Maximum Blocking Factor = 414 (block size 32706)

5. MACHINE READABLE INPUT (MRI)

File Naming Convention.................................................................................... 5 - 1