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Error code

V5 — Only 1 major oculo-visual exam allowed within 12-month period for age under 19 or within 18-month period for age above 65

Eye exam limit reached

The patient already had an insured major eye exam within the allowed period, from any physician or optometrist.

What to do: Ask the patient when and where they last had an eye exam; if within the limit, nothing to fix.

Code
V5
Description
Only 1 major oculo-visual exam allowed within 12-month period for age under 19 or within 18-month period for age above 65

Explanation

Updated October 26, 2026

V5 means the patient already had an insured major eye exam within the allowed period, from any physician or optometrist, so this one wasn't paid.

What it means

V5 means the eye exam went over OHIP's frequency limit. The Ministry's wording: only one major oculo-visual examination is allowed in a 12-month period for patients under 19 or over 65 with a medical condition, and one in an 18-month period for patients over 65 without one.

The limit counts exams by any physician and by optometrists. Under the physician Schedule of Benefits, the periodic oculo-visual assessment (A110A age 19 and under, A112A age 65 and over, $48.90) is limited to one per patient per 12 months. Services over the limit, or to patients aged 20 to 64, are not insured (GP28). The major eye examination (A115A, $53.60, ages 20 to 64 with a listed condition or a valid requisition) is limited to one per patient per consecutive 12 months. A repeat within 12 months stays insured but is payable at a lesser assessment fee (A10–A11). Ophthalmologists bill A237A/A239A ($59.35) under the same GP28 rules (A156).

The Ministry's public OHIP coverage page says patients 65 and over without an eligible eye condition are covered for one major eye exam every 18 months. The physician Schedule sets 12 months for A112A, so check the patient's last exam date carefully.

Common causes

  • The patient had an eye exam at an optometrist within the period
  • Another physician or ophthalmologist billed an eye exam for the patient within the period
  • A repeat exam billed with A110A, A112A or A115A instead of a lesser assessment code
  • The date of the previous exam was misjudged, for example counting by calendar year instead of 12 consecutive months

How to fix it

  1. Ask the patient when and where they last had an eye exam, including at an optometrist.
  2. If the limit was reached, there is nothing to fix on this claim. For A110A or A112A, the Schedule says not to use other visit codes as a substitute when the limit is reached (GP28).
  3. For a follow-up visit after a periodic oculo-visual assessment, the Schedule says to bill a lesser assessment code with diagnostic code 367 (GP28).
  4. If you believe no other exam was done within the period, send a Remittance Advice Inquiry (RAI) through eSubmit, or on form 0918-84, within 7 months of the RA date.

Don't resubmit if

  • The patient had another insured eye exam within the period. The same claim will be refused again.
  • You would be rebilling the exam under a different assessment code to get around the limit.

How APEX handles it

APEX has no correction rule for V5. If nothing else was paid for the patient on that service date, the claim is listed in the Correction Centre under Outstanding for your input; a line paid at a lesser fee stays in your claims as billed and paid. In most cases the right step is to leave it, or mark it Ignored, rather than resubmit. See how APEX works · Pricing

Related codes: M1, D6, V6

Sources