Ontario Health Insurance Plan

INFOBulletin

Temporary Payment Criteria for After Hours Procedure Premiums

Changes to the Schedule of Benefits for Physician Services (Schedule) in response to the COVID-19 outbreak effective November 28, 2020


To: Physicians
Category: Physician Services
Written by: Health Services Branch, Ontario Health Insurance Plan Division
Date issued: November 30, 2020
Bulletin Number: 201110


To further support the government's response to the spread of COVID-19 in Ontario, and physician services in addressing the backlog of surgeries and other procedures that have been delayed due to COVID-19, the Minister of Health has made an Order under the authority of subsection 45(2.1) of the Health Insurance Act.
The Ministerial Order temporarily revises the current payment criteria for physicians to receive a premium when performing after-hours surgical or other procedures as listed in General Preamble in the Schedule of Benefits for Physicians Services (the Schedule).

Physicians (other than Emergency Department Physicians) will now be eligible for payment of the After Hours Procedure Premiums when the service provided is an elective in-hospital, Independent Health Facility (IHF), or non-hospital based surgical or other procedure included in the list of services under item 2 below, and is commenced after hours, on a weekend/holiday, or at night.

This new temporary COVID-19 funding is effective November 28, 2020 until March 31, 2021, unless the ministry and the Ontario Medical Association agree to an extension.

Temporary Payment Criteria

AFTER HOURS PROCEDURE PREMIUMS

  1. These premiums are payable when the following criteria are met:

    1. the service provided is one of the following:
      Non-elective Surgical Procedures (including fractures or dislocations), Obstetrical Deliveries, Clinical Procedures Associated with Diagnostic Radiological Examinations, Ground Ambulance Transfer (K101), Air Ambulance Transfer (K111), Transport of Donor Organs (K102), Return Trip (K112), or one of the following Major Invasive Procedures:

      E111A, G060, G061, G062, G065, G066, G067, G068, G082, G083, G085, G090, G091, G092, G099, G117, G118, G119, G125, G176, G177, G178, G179, G211, G222, G224, G246, G248, G249, G260, G261, G262, G263, G268, G269, G275, G277, G279, G280, G282, G287, G288, G290, G294, G295, G297, G298, G303, G309, G322, G323, G324, G330, G331, G336, G347, G348, G349, G356, G376, G379, G380, G509, J001 to J068
      and;

    2. the procedure is either (a) non-elective; or (b) an elective procedure which, because of an intervening surgical emergency procedure(s) was delayed.
  2. E409/E410 are also payable when the service provided is one of the following elective (a) Surgical Procedures; or (b) Clinical Procedures Associated with Diagnostic Radiological Examinations; or (c) Major Invasive Procedures listed in 1 above.

For services described in 1 and 2 above, premiums are payable as follows when commenced between:

Emergency Department Physician

E412 Evenings (17:00h-24:00h) Monday to Friday or daytime and evenings on Saturdays, Sundays, Holidays-increase the procedural fee(s) by 20%.
E413 Nights (00:00h-07:00h)-increase the procedural fee(s) by 40%.

Physician – other than an Emergency Department Physician

E409 Evenings (17:00h-24:00h) Monday to Friday or daytime and Evenings on Saturdays, Sundays, Holidays-increase the procedural fee(s) by 50%.
E410 Nights (00:00h-07:00h)-increase the procedural fee(s) by 75%.

Payment rules

  1. E409/E410 is not payable for a procedure rendered by an Emergency Department Physician
  2. E412/E413 is only payable for a procedure rendered by an Emergency Department Physician who at the time the service was rendered is required to submit claims using “H” prefix emergency services.

Keywords/Tags

COVID-19; After Hours Procedure Premium; E409; E410

Contact Information

Do you have questions about this INFOBulletin? Email the Service Support Contact Centre or call 1-800-262-6524.

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For More Information

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