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Ministry Status: Routine Monitoring and Engagement

Ontario Health Insurance Plan

OHIP Bulletins

Primary Health Care Services InfoBulletins

To:  GP Focus Care of the Elderly – Model 1 Physicians

Published by:   Negotiations Branch

Date Issued:  August 11, 2016

Bulletin Number:  11155

Re:   COE Agreement Automation (Model 1 - Phase 2 Implementation)

PDF Version Portable Document Format

In late 2013, Phase 1 of the GP Focus Care of the Elderly – Model 1 (COE1) agreement was implemented onto the Ministry Claims Payment System (MCPS) enabling COE physicians to submit claims using their COE group identifier/billing number. As an interim process until the implementation of Phase 2 was possible, claims submitted were suppressed in MCPS and the data was used to calculate COE payments manually.

Effective August 1, 2016, Phase 2 of the COE – Model 1 agreement will be implemented. All COE payments will be fully automated onto MCPS and manual payments will no longer be required.

An explanation of the changes as a result of this implementation is provided below:

  1. Billing/Claims Submission – No Change
    • Physicians will continue to submit claims for all services provided while working as a COE1 physician using their four digit COE group identifier/billing number.
  2. Payments – Change
    • All payments and the corresponding discounts will be calculated and paid through the MCPS, reported on the COE group Remittance Advice (RA) and paid to the COE group bank account.
  3. Q Codes for Patient Enrolment – Change
    • A new Q code – Q205A – Frail Elderly Patient – has been created for COE1 physicians to correctly enrol and identify Frail Elderly patients on ministry systems. (Previously, COE1 physicians were required to use the Q202A Long-Term Care (LTC) enrolment code to identify each Frail Elderly patient enrolled.)
    • Q205A is an enrolment tracking code that will pay at $0 with an explanatory code ”30„ – this service is not a benefit of MOHLTC.
    • Q205A can only be submitted for patients 65 years of age or older. (Patients less than 65 years will reject A2A – Outside age limit.)
    • Q202A will be ended for COE1 physicians effective July 31, 2016 and any Q202A enrolment codes submitted with service dates on or after August 1, 2016 will reject EP5 – Incorrect FSC for group type.
    • The ministry will automatically process a one-time change that will change all patients previously enrolled as LTC (status 15) to Frail Elderly (status 16). COE1 physicians will see this change on their enrolment reporting.
    • COE1 physicians may continue to enrol non-Frail Elderly patients using the Q200A enrolment tracking code.
  4. Q Code for After Hours Payment – Change
    • As before, COE1 physicians can submit and receive fee-for-service (FFS) payment for a defined list of services when provided after hours. In addition, for enrolled patients, physicians will also receive an After Hours Premium equal to 30% of the fee approved value of the service when provided after hours.
    • A new Q code has been created to identify after hours services provided by COE1 physicians. The new Q018A – COE After Hours Premium, replaces the former Q012A and Q094A and should be submitted on the same claim as the associated service provided for services provided August 1, 2016 or later.
    • For enrolled patients of the group, the following codes will pay FFS and Q018A will pay 30% of the fee approved value of the code: A001A, A003A, A004A, A007A, A008A, A888A, K005A, K013A, K017A, K030A, K033A, K130A, K131A, K132A and Q050A.
    • For non-enrolled patients, the following codes will pay FFS and the Q018A will pay $0 with an explanatory code of I6 – Premium not applicable: A001A, A003A, A004A, A007A, A008A, A888A, K005A, K013A, K017A, K030A, K033A, K130A, K131A and K132A.
    • Any other fee codes submitted with the Q018A will pay at $0 with an explanatory code IA – Services billed are not eligible for this premium.
    • Effective August 1, 2016, COE1 physicians are no longer eligible to submit the Q012A or Q094A After Hours codes and they will reject EPA – network billing not approved. (Note: the Q012A and Q094 may still be submitted for any remaining services provided prior to August 1.)
  5. Payment Delays – Change
    • The move from manual payments to automated payment through the MCPS means that there will no longer be a one month delay in claims related bonus and premium payments due to manual processing. (e.g. claims assessed in May are paid on the July remittance advice).
    • The September 2016 COE1 group RA will include all payments calculated by the MCPS for Base, Administration, Fee-for-Service and Shadow Billing Premium along with the corresponding discounts for the processing month of August.
    • Physicians who have previously received their COE payments on their solo remittance advice and paid into their solo bank account will receive their last manual payment in September for claims assessed in July 2016.
  6. Payment Reporting – Change
    • COE1 Group RA Reporting
    • The group RA will provide the group Lead with reporting to assist in dispersing payments to physicians in their groups.
    • Each payment element is provided with a breakdown by physician with month-to-date and year-to-date totals as well as group level reporting.
    • Cumulative year-to-date, current month, and new cumulative totals for both the Fee-for-Service Cap and After Hour Payment Thresholds will also be reported on the group RA.

    Solo RA Reporting

    • Each physician in the group will also receive their own payment information for each payment element reported on their own solo RA.

    For any inquiries please contact the Service Support Contact Centre: 1-800-262-6524 or ServiceSupportContactCentre@moh.gov.on.ca

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