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AC1 Rejection (AC1 Error) - Maximum reached

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OHIP Error Code - AC1 - Maximum Reached

Explanation:

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 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.

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 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 has 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 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 (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?

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