Author: Gregg Mattinson

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OHIP Update: Surgical Unbundling – Effective April 1, 2026

The Ministry of Health and the Ontario Medical Association have introduced changes to how certain pre-operative and post-operative visits are billed under the 2024 Physician Services Agreement.

As outlined in OHIP INFOBulletin 260304, eligible services provided on or after April 1, 2026, may now be paid separately from the surgical fee.

What’s Changing?

Pre-operative assessment Surgeons can now receive full payment for eligible in-hospital pre-operative assessments performed 1–2 days before surgery. Previously, these visits could be included in the surgical fee or paid at a reduced rate.

Same-day surgery assessments

There is no change to the existing rules. Assessments performed on the day of surgery generally remain included in the surgical fee unless specific conditions allow separate payment.

Subsequent visits on the day of surgery

Certain subsequent visit codes can now be paid alongside the surgical procedure fee when billed by the same physician for the same patient on the same day, provided all OHIP requirements are met.

Post-operative assessments

Eligible in-hospital concurrent care and subsequent visits provided within two weeks after surgery can now receive full payment, where they were previously reduced or included in the surgical fee.

What Does This Mean for Physicians?

These changes may allow physicians to receive payment for eligible services that were previously bundled into the surgical fee or paid at a reduced rate.

Physicians should review the updated billing rules and eligible service codes to ensure claims are submitted correctly.

For full details, refer to OHIP INFOBulletin 260304.

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Why are my G codes being rejected?

Why are my G codes being rejected?

MOH will automatically accept the first physician’s billing. If other physicians were involved in the patient’s care, their G-codes may be rejected unless supporting notes are submitted with the claim.

For emergency or critical care physicians, common rejection reasons include:

Exceeded Limits

  • A maximum of 3 physicians can bill G521 for the same patient on the same day.
  • If you are the 4th physician, you must bill G395 instead.

Exceeded Time Limits

  • G395 and G391 have strict time limits. If you bill more units than allowed, the entire claim line may be rejected. Exceeding 9 units of G391 will result in a rejection.

Premium Codes: Resuscitation codes cannot be billed with certain special visit premiums or standard counselling codes.

No Admission Date: If resuscitation occurs during an inpatient stay or upon admission, the Admission Date must be included, or the claim will be automatically rejected.

  • To help prevent these rejections, you can easily add your notes directly in the Agent+ app: Open the claim and scroll down to “Manual Review.”
  • Select the applicable service code(s).
  • Choose “Add Document” and attach your notes.

Providing your notes at the time of billing helps MOH verify the services and can reduce delays in payment.

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Life-Threatening Critical Care & Resuscitative Care

Life-Threatening Critical Care & Resuscitative Care
These are two types of critical care provided during emergency situations. Life-threatening critical care applies when a patient is critically ill or injured and has a serious impairment of one or more vital organs that may lead to organ failure.

Billing Codes: G521, G522, G523

Note: Up to 3 physicians can bill G521 for the same patient on the same day. If a 4th physician provides this service, they must bill G395 instead.

Resuscitative Care

Resuscitative care is provided in an emergency when the patient does not meet the criteria for life-threatening critical care but is still at risk of:

  • Loss of life
  • Loss of a limb
  • Requiring life-threatening critical care

Billing codes: G395, G391

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Error codes

Error codes and what they mean:

Level 1 Error Codes are errors returned by the MOH that can typically be corrected and resubmitted. These errors mean you have the opportunity to make the necessary changes to the claim and resubmit it for processing.

Level 2 Error Codes are errors identified and assessed by MOH. These errors appear on your Remittance Advice (RA). To request payment on these claims, you must submit a Request for payment by submitting an RAI with your documentation.

Error 35 (Level 1)
This error means payment has already been issued for this patient, date of service, and billing number. It may occur if a duplicate claim was submitted or if another claim with different service codes was already paid for the same date. This error cannot be disputed unless you can confirm that you were not paid on a previous Remittance Advice.

Error EH2 (Level 1)
Invalid Health Card: The health card used for the date of service is no longer valid and has a new version code. Contact the patient for their updated version code or contact Agent+ if you are signed up for the MOH PIN service and are on an Assisted or Full Service tier.

Error code 55/57 (Level 2)
Code 55: Shows a deduction or adjustment from a previous payment.
Code 57: Shows the corresponding payment adjustment for the previous account. These two codes are usually listed together, one after the other.

Special visit premiums (SVP’s) are not payable for:

  • Hospital or long-term care home rounds or elective admissions.
  • Visits to facilities (other than hospitals or long-term care homes) that are open to diagnose or treat patients.
  • Visits to non-referred or transferred obstetrical patients.
  • Patients seen without an appointment while the physician is already in the office, before, during, or after office hours.
  • Visits where a critical care team fee or per diem fee is payable
  • Emergency Department (ED) visits where an “H” prefix code is payable, except for the premiums listed in Special Visit Premium Table V for ED physicians called in when they are not scheduled to work and are not already at the hospital.
  • Services provided in conjunction with any sleep study listed in the Sleep Studies section of the Schedule.
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App Maintenance

App Maintenance

Unfinished Claims
Any unfinished claims are now being stored in the “In Progress” folder. Please refer to this folder as needed.

Agent+ Cleanup
Agent+ performs an annual audit to mass-settle claims that are no longer eligible for payment/dispute, helping keep your app organized and free of clutter. This will affect all billing tiers.

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Agent+ Portal

Agent+ Portal

If you have questions about your payments in addition to your app’s resolved folder you have access to our online portal, where you can view a digital copy of your Remittance Advice (RA) in an easy-to-read format.

Understanding your Agent+ RA

PARTIAL & NON-PAYMENTS: The Ministry of Health (MOH) has partially paid the fee service codes listed below. An explanatory error code has been provided.

MOH PAYMENT MODIFICATIONS: MOH has adjusted the payment amount for the fee service code listed below and has provided an explanatory code for the adjustment.

MOH ADJUSTMENTS: MOH has returned these claims on more than one remittance advice. The complete payment and adjustment history for each claim is displayed. This section will indicate whether there were any claw backs or returned RAI payments. Error codes 55/57 will typically appear in this section.

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New diagnostic code

New diagnostic code:

To support data collection efforts by Public Health Ontario, MOH has introduced diagnosis code 489 – RSV: Respiratory syncytial virus. This diagnostic code should be used with the appropriate assessment service fee code when a patient is diagnosed with RSV or administered (G538A) an immunization. It must be the primary reason for the visit.

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Provider Registration

Provider Registration

Effective April 1, 2026, the Ministry of Health moved to one submission process and is now only using electronic submissions.

Providers must now submit registration and update requests through the secure online portal for the following services: https://forms.mgcs.gov.on.ca/en/dataset/on00574

  • OHIP Billing Number registration
  • Health Care Group registration
  • Group membership and payment consent/authorization
  • Changes to address, banking, or group information
  • IVR participation applications Social Assistance Verification Portal PIN requests
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New Phone?

Reinstalling Agent+ on a New Phone – CANNOT USE BACKUP

If you get a new phone, do not use a backed-up version of the Agent+ app. Before switching over, make sure you submit any claims that are ready for submission from your old phone. Once you have restored your new phone from a backup, delete the Agent+ app from the new device. Then, download a fresh version of the Agent+ app from the App Store and log in using your existing credentials. Once you log in, all your Agent+ information will automatically import back into the app. This ensures you are using the current version of Agent+ and prevents issues that may occur when using a backed-up version of the app.

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Out of Canada?

Out of Canada

The Agent+ app cannot be used to submit claims while outside of Canada due to PHIPA requirements. However, you can still log into Agent+, create new claims, and save claims while travelling or working abroad. Any claims created or saved outside of Canada will remain available in the app, but claims cannot be submitted until you have returned to Canada. Once you are back in Canada, you can submit your completed claims through Agent+ as usual.