OHIP Error Code - AC1 - Maximum Reached
What is OHIP error code AC1?
You have reached the maximum number of times you can bill this code within a time period. Here are the payment rules:
If a Full and Limited Consult has been billed within the last 12 month period, no other Full or Limited Consult is eligible unless it is for an unrelated diagnosis
Full and Limited Consults rendered to the same patient with the same diagnosis are limited to ONCE per 24 month period unless the second consult was conducted in a Hospital Inpatient or ER department.
How to fix OHIP error code AC1?
Consider billing a lower-paying code (e.g., if originally billed a Consultation, then resubmit with a Repeat Consultation or a Medical Specific Assessment, whichever is applicable). Alternatively, if the patient is seen for a second time with a clearly defined unrelated diagnosis, you may consider billing the same service code again with a different diagnosis code.
**Please note: claims submitted appropriately for an additional consult by the same provider to the same patient but with a different diagnosis within the same year have incorrectly been rejected by the MoH claims payment system. The medical rule that caused these rejections have been identified, and a solution is being generated by the MoH. Please refer to OHIP Bulletin #4736 for more details. In this scenario, you can resubmit the claim with manual review and/or fax a note to the MoH to request an explanation. Here's how to submit a Manual Review.
For further information you can do the following:
1. Reviewing the Schedule of Benefits. Here is the link to the SoB: Physician Services Under the Health Insurance Act (GP16-17). Note: the payment rules of Consultation have been changed since Oct 2019; or
2. Contacting your Ministry of Health Claim Assessor for advice: How do I find my Claim Assessor?