ONTARIO · ARTICLE
What triggers AT3, EH2, AC1 and VJ7/VJ8, how to fix each one, and the habits that stop them before a claim goes out.
By Robin, Expert Biller, ResolvMD · 6-minute read
Most OHIP rejections fall into a short list of recurring patterns. Four codes (AT3, EH2, AC1 and VJ7/VJ8) account for a large share of claim rejections across Ontario practices. Each is correctable, and most are preventable. The catch is timing: by the time a rejection shows up, the claim has already missed a payment cycle.
This guide covers what triggers each code, how to fix it, and what to put in place so it doesn’t happen again.
Quick reference
| Code | OHIP description | Core cause | What’s at stake |
|---|---|---|---|
| AT3 | No patient-physician relationship | Comprehensive virtual service billed without an established relationship | Claim rejected or downcoded |
| EH2 | Invalid version code | Health card version code is outdated or wrong | Frequent rejections across your patient list |
| AC1 | Maximum reached | Initial consultation already billed for this diagnosis in the past year | Full fee can’t be recovered |
| VJ7 / VJ8 | Stale-dated claim | Submitted more than three months after the date of service | Revenue at risk of permanent loss |
AT3No patient-physician relationship
Why it triggers. AT3 flags comprehensive virtual care claims where OHIP can’t verify an existing patient-physician relationship. In most cases that means an in-person visit with you in the preceding 24 months; a few other routes also qualify (see the Ministry’s virtual care billing brief). If that baseline visit isn’t on file, or hasn’t been processed yet, the virtual claim is rejected.
How to fix it. If an in-person visit did happen but hasn’t cleared yet, wait for that claim to process, then resubmit the virtual service. If no qualifying relationship exists, bill limited virtual care (A101 or A102) if clinically appropriate and resubmit.
How to prevent it. Flag new virtual care patients at intake so their first appointment is in person. Set EMR alerts for patients without an in-person visit in the last 24 months before a virtual billing code is applied.
EH2Invalid version code
Why it triggers. EH2 is triggered when the two-letter version code on your claim doesn’t match what the Ministry has on file for the date of service. That happens when a patient’s health card has expired, been reported lost, or been renewed, creating a new version code your billing system doesn’t have yet.
How to fix it. Ask the patient for the letters on their current card, check hospital or regional EMR records for updated demographics, or call ServiceOntario for the updated version code. Update the patient’s billing profile and resubmit.
How to prevent it. Check or swipe the health card at every visit. Version codes never contain the letters I or O, so if you see either, something is wrong. Real-time Health Card Validation (HCV) in your EMR catches mismatches before the claim goes out.
AC1Maximum reached
Why it triggers. AC1 means the maximum for that service has already been billed, and it hits specialist consultations most often. Once an initial consultation has been billed for a patient, another initial consultation for the same diagnosis can’t be billed within one year (365 days). If the patient comes back within that year with the same diagnosis, the second initial consultation is rejected.
How to fix it. If it’s the same diagnosis, bill a reassessment instead and resubmit. If the visit was for a different diagnosis, update the diagnostic code and resubmit it as a new initial consultation.
How to prevent it. Before submitting a consultation, check the chart for an initial consultation for the same diagnosis in the past 365 days. EMR billing history tools can flag these automatically.
VJ7 / VJ8Stale-dated claim
Why it triggers. For services on or after April 1, 2023, OHIP claims must be submitted within three months of the date of service (it was six months before that). Claims submitted after the deadline are rejected as stale-dated.
How to fix it. If the date of service is a data-entry error, correct it and resubmit. Otherwise, the route depends on the claim’s history:
- Submitted on time, then rejected: correct the claim, resubmit it through MC EDT as a stale-dated claim file, and email supporting documentation (the error report and claim details) to ClaimsManagement@ontario.ca.
- Never submitted: send a signed letter on letterhead to ClaimsManagement@ontario.ca explaining the extenuating circumstances. The Ministry reviews each request, and approval isn’t guaranteed.
How to prevent it. Submit to MC EDT on a fixed weekly schedule rather than batching at month-end, and review unsubmitted claims every week so nothing ages past the window.
Official sources
Rejections, worked for you
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