Ross Male

The General Manager of OHIP brought a motion to dismiss a physician's appeal regarding the denial of sixteen claims for fee code W010.

The claims were denied because they were not submitted with the correct enrollment information within the prescribed six-month timeframe.

The Physician Payment Review Board found that the claims were refused under s. 18(3) of the Health Insurance Act for failing to meet prescribed requirements, rather than under s. 18(2).

Consequently, the Board concluded it lacked jurisdiction to hear the appeal, as decisions under s. 18(3) can only be challenged by way of judicial review to the Divisional Court.

The motion was granted and the appeal dismissed without costs.

The applicant physician appealed the General Manager's denial of five claims for surgical procedures.

The General Manager argued the claims were stale dated under s. 18(3) of the Health Insurance Act because the applicant failed to submit requested operating room notes within six months of the service date.

The Physician Payment Review Board found that the claims were submitted within the prescribed time and that the request for operating room notes constituted an interim assessment under s. 18(2), not a prescribed requirement under s. 18(3).

The Board ordered the applicant to resubmit the claims with the notes for a fresh assessment by the General Manager.

The General Manager of OHIP brought a motion to dismiss a physician's appeal for lack of jurisdiction.

The General Manager had denied the physician's claims for insured services, arguing the physician failed to submit supporting documentation within the prescribed six-month timeframe under s. 18(3) of the Health Insurance Act.

The General Manager contended that appeals of s. 18(3) decisions can only be heard by the Divisional Court on judicial review.

The physician argued the claims were submitted in compliance with the Act and should be assessed under s. 18(2), which the Board has jurisdiction to hear.

The Physician Payment Review Board dismissed the motion, finding it has jurisdiction to determine whether the General Manager appropriately interpreted the scope of 'prescribed requirements' under s. 18(3) and whether the refusal more properly falls under s. 18(2).