Government of Ontario: Ministry of Health

Claims Flagged for Manual Review

This form is for manual review only. DO NOT use this for inquiries. Submit the completed form(s) with your disk/tape.

A. Provider Information

Provider/Group Number
Provider's Name
Office Contact Name

Office Contact Phone No. ( ) Extension

B. Patient Information

Health Number
Patient's Name

Date of Birth (yyyy/mm/dd)
Service Date Service Code
Account Number (if available)

C. Detention Time (including report and time spent with patient)

K001A: Time spent exclusively with the patient following the consultation/assessment. Refer to the Schedule of Benefits, General Preamble for conditions and limitations.

Assessment Start Time Hr. Assessment End Time Hr.

Detention Start Time Hr. Detention End Time Hr.

K101A: Time of Departure Patient(s) Hr. Time of Arrival Hr.

K111A: Boarding Time Patient(s) Hr. Disembark Time Hr.

K112A: Return Without Patient(s) Time of Departure Hr. Time of Arrival Hr.

K102A Time of Departure Hr. Time of Arrival Hr.

K102A (Return) Time of Departure Hr. Time of Arrival Hr.

Critical care with report including time spent with patient when providing resuscitation
(indicating actual beginning and ending time)

Start Time Hr. End Time Hr.

D. Independent Consideration procedures or complex medical procedures, include an operative report and comparision with a listed service in terms of scope, difficulty and value.

For other fee schedule codes requiring additional documentation, please refer to the Schedule of Benefits, General Preamble.

E. Multiple visits same day: (state clinical reason)

Code Time of 1st visit Hr.
Reason

Code Time of 2nd visit Hr.
Reason

Code Time of 3rd visit Hr.
Reason

F. Other:

Other:

Instructions for
Claims Flagged for Manual Review

Do not use Manual Review Indicator if you are not sending documentation.

Do not use for:

stale-dated claims
E409A / E410A, E400B / E400C and / et E401B / E401C
inquiries (overpayment, underpayment, non-payment)
procedures that require prior approval

Complete and submit the form(s) at the same time you send in your diskette/tape.

Note: Make sure Provider number is clearly indicated on the form(s). Unidentified documents will be destroyed.

Use this form for:

duplicate service code claimed for the same date, different time
claim resubmitted with a requested operative report
statement from operating surgeon substantiating 2 surgical assistants
suppression of service verification
specific services which you want to be manually reviewed by the Ministry
out-of-province referring provider information (e.g. name and address)
statement from operating surgeon to substantiate claim for M400B assistant fee when no basic fee is listed
anesthetic or assistant claims where total units exceed "99" - see Data Link (93-004) Divisional Communication, August, 1993

2404-84 (2022/11) 7530-5248

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