OHIP claim rejections in 2026: the most common errors and missed premiums
Which OHIP errors cost Ontario physicians the most time in 2026, and which premiums are most often left unbilled? We counted them in anonymized APEX data for 223 billing numbers, services from January 1 to September 30, 2026.
- 72,500 rejected claim lines
- 43% health card errors (EH)
- 213 of 223 billing numbers hit by EH2
- $143,122 missed Q012A premiums
Three error families caused most rejections
The Error Reports held 72,500 rejected claim lines. Three families of codes appear on most of them.
| Error family | What it means | Rejected lines | Share |
|---|---|---|---|
| EH (EH1, EH2, EH4 and others) | Health card version, eligibility or registration problem | 30,954 | 43% |
| EP (EP1, EPA, EPC and others) | Enrolment or network billing problem | 14,170 | 20% |
| AT3 | No patient-physician relationship | 9,710 | 13% |
| VH (VH1, VH8, VH9 and others) | Health number or date of birth problem | 2,990 | 4% |
| VJ7 | Stale-dated claim, received more than 3 months after the service | 1,617 | 2% |
Some lines carry two or three codes at once (for example EP1 with EH2), so a line can count in more than one family.
EH2: mismatched version code
- 30,447 rejected lines
- 213 of 223 billing numbers affected
- What it is: the patient's health card was renewed and the claim went out with the old version code.
- How to prevent it: check the version code at the visit with health card validation (HCV). That prevents most of them.
Most EH2 rejections were on everyday visits: A007A, A003A, K301A, Q012A and K013A.
EP1: roster request refused
- 9,633 Q200A lines rejected with EP1
- 122 billing numbers affected
- What it is: rostering a patient with Q200A failed with EP1 (enrolment transaction not allowed), usually together with EH2 or EH4.
- Why it happens: the health card details didn't match, or the patient was already enrolled elsewhere.
- How to prevent it: make sure the health card details match and the patient isn't enrolled elsewhere before you bill Q200A.
AT3: no patient-physician relationship
- 9,710 rejected lines
- 137 of 223 billing numbers affected
- 5,375 on K013A counselling
- What it is: OHIP had no record of an ongoing relationship with the patient for a service that needs one. This is common after the virtual care rules changed.
- How to prevent it: check the relationship rules for K013A and virtual care before you bill.
AT3 was concentrated: over half were on K013A counselling (5,375 lines), at 42 billing numbers. Most of the rest were on A007A (3,418).
The codes rejected most often
Share of claim lines rejected per fee code, counting only codes billed at least 500 times at 5 or more billing numbers. For comparison, A007A was rejected 2.9% of the time and A003A 3.1%.
| Fee code | What it is | Share rejected |
|---|---|---|
| Q053A | New complex or vulnerable patient from Health Care Connect | 96.2% |
| K130A | Periodic health visit, ages 16 and 17 | 49.0% |
| E078A | Chronic disease assessment premium | 48.7% |
| Q313A | FHO+ clinical administration (hourly) | 36.9% |
| A002A | 18-month developmental assessment | 35.0% |
| Q015A | Newborn care episodic fee | 24.4% |
| K039A | Smoking cessation follow-up | 19.5% |
| Q042A | Smoking cessation counselling fee | 16.8% |
| A905A | Limited consultation | 14.6% |
| Q016A | After-hours premium (CCM) | 11.6% |
| Q402A | De-roster ended by the physician | 10.3% |
| A005A | Family practice consultation | 10.0% |
Q053A: HCC requirements not met
- What it is: almost every rejected Q053A (2,806 lines, at 13 billing numbers) came back with HCC. The patient wasn't on Health Care Connect as complex or vulnerable in 'referred to' status.
- How to prevent it: confirm the patient's HCC status before you bill Q053A.
K130A: outside the age limit
- What it is: most K130A rejections (583 of 613 lines) were A2A: the patient wasn't 16 or 17 on the service date.
- How to prevent it: check the patient's age and bill K131A for adults 18 to 64.
FHO+ hourly codes (Q310A–Q313A)
- What it is: new codes from April 1, 2026. Q313A clinical administration was rejected 36.9% of the time; Q310A, Q311A and Q312A only 3% to 5%.
- Why it happens: the hourly codes have their own rules on time units, dates and who can bill them, and Q313A has the tightest limit.
- How to prevent it: check time units, dates and the Q313A limit before you send FHO+ hourly claims.
PAA on K039A and E079A
- What it is: 322 of the 734 K039A and E079A rejections (44%) were PAA. The follow-up was billed without an initial smoking cessation fee (E079) paid in the prior 365 days.
- How to prevent it: confirm E079 was paid in the prior 365 days before billing the follow-up.
What the Remittance Advice showed
Paid claims carry explanatory codes too. Most aren't errors, but some reduced payment.
| Code | Meaning | Lines | Effect |
|---|---|---|---|
| 30 | Service is not a benefit of OHIP | 230,889 | Almost all $0 lines |
| I2 | Globally funded | 122,708 | Not an error |
| 35 | Duplicate | 48,620 | Already paid |
| B2 | Paid at the phone virtual care rate | 47,494 | Not an error |
| I6 | Premium not applicable | 26,619 | Reduced payment |
| D3 | Not allowed in addition to the visit fee | 10,662 | Reduced payment |
| EV | Check health card for the current version | 6,926 | Reduced payment |
| M1 | Maximum reached | 3,541 | Reduced payment |
| R1 | Only one health exam in 12 months | 3,323 | Reduced payment |
| B8 | Not payable as a virtual service | 1,456 | Reduced payment |
For an FHO physician, I2 just means the visit was shadow billed for a rostered patient. Code 30 lines were billed at $1,885 in total, so they are mostly zero-fee tracking codes.
35: duplicate claims
- 48,620 duplicate lines
- 198 of 223 billing numbers affected
- What it is: the same service had already been claimed and paid. It isn't money lost, but each one is a claim someone sent twice.
- Why it happens: often a resend after a rejection that was already fixed, or two systems sending the same visit.
- How to prevent it: don't resend a claim that was already fixed, and send each visit from one system only.
Premiums left unbilled
APEX also checks paid claims for services billed below what they qualified for. These are the most common gaps it found for 2026 service dates.
| Missed or underpaid | What happened | Visits | Average per visit | Total |
|---|---|---|---|---|
| Q012A after-hours premium | Weekend or holiday visit with a rostered patient and no Q012A | 4,933 | $29.01 | $143,122 |
| K005A paid below schedule | K005A with A007A or A003A cut by D3 | 1,604 | $83.85 | $134,500 |
| Minimum/maximum (D3) | Paid less than the highest code billed that day | 866 | $21.31 | $18,454 |
| A101A/A102A with an existing relationship | Limited virtual code used when A007A plus K300A or K301A applied | 881 | $19.61 | $17,279 |
| E089A 20% add-on | Periodic health visit (K131A or K132A) for an eligible patient without E089A | 960 | $9.23 | $8,863 |
Missing Q012A after-hours premium
- What it is: a Saturday, Sunday or holiday visit with a rostered patient qualifies for Q012A (Q016A for CCM). Since April 1, 2026 it pays 50% for FHO physicians.
- How to prevent it: look for weekend and holiday visits without Q012A.
The most common gap. It turned up at 124 billing numbers.
K005A cut by D3
- What it is: when K005A (primary mental health care) is billed with an assessment, OHIP can pay it below the schedule. The most expensive gap per visit.
- How to prevent it: check the diagnostic code. K005A should carry a mental health diagnosis such as 300.
What to do with this
If you bill in an FHO, FHG or CCM, add these checks to your routine.
- Check version codes before you send. EH2 is the most common avoidable rejection, and it is avoided by validating the health card at the visit.
- Check enrolment before rostering. EP1 on Q200A was the second most common rejection.
- Check the rules on Q053A, K130A and E078A. They were rejected more often than any other common code.
- Look for weekend and holiday visits without Q012A. It was the most common missed premium.
How we counted
- Service dates: January 1 to September 30, 2026
- 223 billing numbers, mostly family medicine
- Counts only, no patient details
Data sources and limits
The data is the Error Reports and Remittance Advice that APEX read from MCEDT for 223 billing numbers, for services from January 1 to September 30, 2026.
We counted Error Report lines that carry an error code, explanatory codes on Remittance Advice lines (leaving out 55 and 57 adjustment pairs), and claim adjustments found by APEX.
We report counts only. No patient details were used, and any code seen at fewer than 5 billing numbers is left out.
The practices are mostly family medicine, so specialty patterns are under-represented.
Error Reports can lag by a few weeks, so July to September counts are lower than earlier months. A claim that was rejected, fixed and rejected again counts each time.
Shares are rounded to the nearest whole percent in the family table. Billing numbers are counted, not named, and no patient information was read or published.
APEX offers every physician or group a unique, transparent overview over their billing records.