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AC1 Rejection (AC1 Error) - Maximum reached

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Explanation:

You have reached the maximum number of times you can bill this code within a time period.  For example, consults/(re) assessments have limits on the number of times you can bill in a 12-month period under certain circumstances.

Solution:

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 refer to the Schedule of Benefits section GP12-13 for more details about the payment rules of Consultation (*Note: the payment rules have been changed since Oct 2019). If the payment rules are met but the claim is still rejected with an AC1 error. You can resubmit the claim with manual review and/or fax a note to the MoH to request for an explanation. For instruction on submitting a Manual Review, see OHIP Billing Tip #11 - 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; or
2. Contacting your Ministry of Health Claim Assessor for advice: How do I find my Claim Assessor?

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