OHIP Billing: Common Rejection Codes Related to Referring Physicians and How to Avoid Them

When submitting claims to OHIP, one of the common areas of rejection pertains to errors with referring physician information. Understanding the most frequent rejection codes and implementing preventative measures can significantly improve claim approval rates. Below, we explain these codes, their causes, and how RexEMR minimizes such errors.

Common Rejection Codes and Their Explanations

1. ARF (Invalid Referring Physician Number):
   • Description: This error occurs when the referring physician’s billing number is missing, invalid, or does not exist in OHIP’s database.
   • Prevention: Ensure that the referring physician’s billing number is accurate and active. RexEMR maintains a comprehensive repository of all Ontario physicians’ billing numbers, reducing the likelihood of this error.
2. ARP (Referring Physician Number Not Provided):
   • Description: This code indicates that a referring physician’s billing number was not included in the claim.
   • Prevention: RexEMR’s built-in validation ensures that users cannot submit claims without entering the referring physician’s billing number.
3. EQ6 (Physician Not Eligible to Refer):
   • Description: This error occurs when the referring physician is not authorized to make referrals according to OHIP’s eligibility criteria.
   • Prevention: RexEMR validates the referring physician’s eligibility status before claim submission, ensuring compliance with OHIP regulations.
4. ERF (Referring Physician Number Expired):
   • Description: This rejection happens when the referring physician’s billing number is no longer valid due to expiry or deactivation.
   • Prevention: By keeping an updated repository of physician billing numbers, RexEMR flags expired or inactive numbers before submission.
5. PA3 (Invalid Specialty for Referral):
   • Description: This code is returned when the referring physician’s specialty does not align with the service being claimed.
   • Prevention: RexEMR ensures that specialty details are cross-referenced with claim requirements during data entry.
6. EF7 (Referring Physician Information Missing):
   • Description: This error occurs when essential details about the referring physician, such as their billing number, are incomplete.
   • Prevention: RexEMR’s mandatory fields for referring physician information ensure completeness before allowing submission.

How RexEMR Minimizes Billing Rejections

1. Comprehensive Physician Repository: RexEMR maintains a centralized, up-to-date database of all physicians in Ontario, including their billing numbers. Once a physician’s billing number is added by any user, it becomes accessible to all system users. This shared repository minimizes data entry errors and eliminates the need for repeated manual entries.
2. Built-in Validation Rules: RexEMR’s system enforces validations that:
   • Prevent submission of claims without referring physician numbers.
   • Cross-check the accuracy of billing numbers and physician eligibility.
   • Flag expired or inactive billing numbers before submission.
3. Real-Time Error Detection: Errors such as missing, invalid, or mismatched data are identified and flagged during the claim preparation process, allowing users to make corrections before submission.
4. Specialist Office Billing Support: For specialist office billing, RexEMR’s system ensures that referring physician details are not only mandatory but also verified, reducing the possibility of errors.

Conclusion

Errors related to referring physician information, such as ARF, ARP, EQ6, ERF, PA3, and EF7, can lead to claim rejections, causing delays and financial losses. By leveraging RexEMR’s robust validation processes, shared physician repository, and real-time error detection, clinics can significantly reduce these errors, ensuring smoother OHIP billing workflows.