OHIP Billing Glossary
The date by which claims for the given billing cycle must be submitted or resubmitted in order to be returned on the following month’s Remittance Advice (RA). These dates are determined by the Ministry of Health (MOH).
Click here for upcoming cut-off dates.
A remittance advice is a monthly statement that details the claims processed for the prior month’s billing cycle and cheque amount OHIP will deposit into your bank account that month. The RA will advise whether a claim has been paid or rejected (paid partially or not at all).
There are two types of errors.
Rejections AKA Level 1 Rejections: Claims are returned by MOH on an error report as they failed the MOH’s system’s initial review. An error code is provided to explain why the claim returned, the claim can be edited and resubmitted. You have 6 months from the date of service to resubmit the claim.
Partial & Non-Payments AKA Level 2 Rejections: Claims are returned with an explanatory code on an RA and can be partially paid or fully unpaid. Depending on the explanatory code, the claim may be disputed with a Remittance Advice Inquiry (RAI) with which an explanation and/or documentation is required. You have 4 months from the date the claim returned on the RA to submit an inquiry. Inquiries are reviewed by an Adjuster at the Ministry of Health.
Claims 6 months past the billing date. They can be submitted under special consideration but will require review of an Adjuster and may take a few months to return.
The 2 letters at the end of a health insurance number that change every 4 years. Use Health card validation to determine whether you have the correction version code.
Claims not covered by OHIP
The provinces and territories of Canada have agreements with one another that you can submit a claim with all the same patient demographics used for an OHIP claim (Health insurance #, Name, Date of birth, sex) and the payment will be provided through OHIP – on your monthly RA and included in the cheque deposit. RMB claims can be submitted in the app by changing the insurance provider on the Patient Info screen.
For more information, see the How-To page.
Claims that cannot be processed by submission to the Ministry of Health.
IFH (Interim Federal Health) – Blue Cross coverage for Canadian residents with a refugee status
Armed Forces – Blue Cross coverage for members of the Armed forced
UHIP (University Health Insurance Plan) – Sunlife coverage for university students subsidized by the Ontario government
Private Billing (bill patient directly) – If a patient does not have insurance coverage. Most commonly used when the patient is not a Canadian citizen or their OHIP coverage is invalid
Private Insurance – Most commonly used for services not covered by OHIP
It is the total billed $ value for claims that are returning on this Remittance Advice (RA) for the first time.
The Ministry may adjust the value of the claims on your Remittance Advice up or down from the invoiced value and provide ** as the explanatory code. This explanatory code means the payment is final and the claim cannot be disputed. These claims show on your monthly Remittance Advice as a ‘Payment Modification’, and will appear in your Partial & Non-Payments if the claim was underpaid by $5 or more – learn more about Partial & Non-Payments in the Error section under Basics on this page. Claims paid within $5 of the invoiced value or overpaid are automatically written off and moved to your ‘Resolved’ folder.
Claims that have previously returned on a Remittance Advice will return on an RA for 2 purposes:
- Claw Back Partial & Non-Payments: A fee service code that was being previously paid is being clawed back. Mostly commonly this occurs because an Adjuster made a mistake on the prior RA or due to an internal audit at MOH.
- RAI returns: Additional payment is being provided for a claim that was previously paid on a Remittance Advice, generally as a result of an RA Inquiry submitted.
There are certain circumstances, when MOH is not able to process claims received for a particular billing cycle. In this case, MOH will advance an amount of money to ‘cover’ the claims they were not able to process. This advance is not an exact amount for unprocessed claims, but an estimated 90% of the amount of outstanding claims. An Advance is always a good indication that MOH has received the claims and you will not be ‘out of pocket’ for the unpaid claims. Although MOH does not provide an actual reason as to why claims are not yet processed, here are 3 possibilities:
1. Claims Assessors Are Not Available
- Claims adjusters may be at a shortage for a number of reasons including the amalgamation of MOH District offices, such as the recent amalgamation of Hamilton District office and Mississauga District office. The transition has resulted in a number of early retirements, extended absences of claims adjusters, staff shortages, and thus advance payments for many of the physicians registered with the Mississauga District office.
2. Claims Received are Close to MOH ‘Internal Cut-off’
- There is a 48 hour delay from when files are transmitted and accepted by the Ministry to when they may make it your MOH Adjuster for manual review that is sometimes necessary. Although the Ministry guarantees processing all claims submitted prior to the OHIP Billing cut-off date, they also have an internal cut-off date which generally falls in the last week of the month. If a batch of claims is submitted just prior to the ‘internal cut-off date’, but with not enough time to be reviewed by an adjuster, they may provide you an advance for these unprocessed claims.
3. Complicated Claims or Claims that Conflict with Patients Billing History
- Claims can potentially conflict with historical information on file with the Ministry. The claim may require significant attention by the claims assessor due to the complexity of the claim. MOH will often provide an advance payment which will give extra time for the assessor to review the claims.
- Payment Reduction-Opted In
- Payment Reduction-Automated Premiums
- Payment Reduction-Primary care
The amount of the OMA fees deductions are based on the $ value of OHIP fee service codes paid on an RA. Claims that are submitted with the “RMB” payment program type for services rendered to insured residents of another province are not subject to the payment discounts, as OHIP will receive 100% of the payment from the reciprocal province.
Details of the the ‘physician payment discount’ are available in the bulletin that was released on April 1 , 2013.