Ontario Health Insurance Plan

Claims Submission

This document is technical in nature and is available in English only due to its limited targeted audience.
This publication has been exempted from translation under the French Language Services Act.

 

Ce document est de nature technique et est disponible en anglais uniquement en raison de son public cible limité. Ce document a été exempté de la traduction en vertu de la Loi sur les services en français.


Method of Submitting Claims

All claims must be submitted through medical claims electronic data transfer (MCEDT) in accordance with Regulation 552, Section 38.3 of the Health Insurance Act (HIA).

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Medical Claims Electronic Data Transfer (MCEDT)

The MCEDT is a secure web-enabled service that offers a:

  • simple user interface (web page) with basic upload and download functions using an internet connection; and
  • a web service for complete automation and integration with Electronic Medical Record (EMR)/Clinic Management System (CMS) software or billing software systems.

The web page is not intended for use with automated programs or scripts. The MCEDT web page is suitable for those with a low number of daily file uploads. File uploads and downloads are a manual process and cannot be scripted or integrated with a systems interface.

Users of the web service will require third party software/vendor to develop a fully automated system to submit and receive files. The MCEDT Technical Specifications for the web service is located on the ministry website.

Some of the key benefits of the MCEDT service include:

  • Secure user authentication
  • Ability to designate access to administrative staff, third party agents or other health care providers, to act on your behalf for the submission and/or reconciliation of claim files
  • Additional electronic reports

The MCEDT service is available 24 hours a day, seven days a week with the exception of weekly scheduled system maintenance on Sunday mornings between the hours of 1:00 am and 5:00 am and Wednesday mornings between the hours of 5:00 am to 8:00 am.

The MCEDT service currently supports the following file types:

  • Medical Claims
  • Stale Dated Claims
  • Overnight Batch Eligibility Checking (OBEC)

For further information on MCEDT and how to register, please refer to the ministry’s webpage on MCEDT and the MCEDT Reference Manual.

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Process to Submit Claims

Claim files must be submitted in a specific file format as outlined in the Technical Specifications-Interface to Health Care Systems manual.

You should contact a software vendor to determine the most appropriate hardware and billing software that would meet your needs based on your business practices and technical capabilities. All hardware and software must conform to the specifications as contained in the Technical Specifications-Interface to Health Care Systems manual.

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Submission of Claims

Types of Claims

HCP Claim

Health Care Payment (HCP) claims are claims for services rendered by physicians or private medical labs to a patient with Ontario health insurance coverage.

  • Payment program “HCP
  • Payee-“P” for pay provider
  • Payee-“S” for pay patient

Note: Payee is dependent on whether you opted in or opted out when you registered.

WSIB Claim

Workplace Safety and Insurance Board (WSIB) (formerly Workers’ Compensation Board (WCB)) claims are for services rendered to patients with Ontario health insurance coverage who have work related injuries.

  • Payment program is WCB
  • Payee is “P” for pay provider
  • If the patient is assessed for a non-WCB related problem during a WCB visit (minor assessment only), A008A (Mini Assessment) may be payable. Refer to the Schedule of Benefits, sections General Preamble and Consultations and Visits
  • A008A cannot be billed on the same claim as the WCB service. It must be billed on a separate HCP claim. A008A can be billed only when the WSIB claim is for A001A
  • If the physician bills any service on a WCB claim other than a minor or partial assessment, no other assessment can be submitted as an HCP claim.

Note: Other than the payment program, the information required to bill is the same as for HCP claims.

The following services are excluded from WCB submissions to the ministry:

  • Service codes prefixed by “T” or “V”
  • Lab services provided by private medical laboratory facilities
  • Services provided by hospital diagnostic departments
  • Services rendered to patients registered in other Canadian provincial plans
  • Services rendered by out-of-province physicians
  • Fee schedule codes: A008, K018, K021, K051, K053, K061, P004, P006
  • Charges for completion of form, such as M640 (must be billed directly to WSIB)
  • Services provided by OPTED-OUT health care providers

RMB Claim

Reciprocal Medical Billing (RMB) claims are submitted to bill for services rendered by physicians to a patient insured under another Canadian provincial/territorial health coverage plan, excluding Quebec.

  • Payment program-RMB
  • Payee-P for pay provider

Note: Except for the section on patient information all other areas are identical to those on the regular HCP claim.

When treating an out-of-province (OOP) resident, view their health card. If there is an expiry date on the card and the card has expired, do not submit a reciprocal claim. In such a case, the patient is responsible for any charges. The physician must provide the patient with a detailed form/invoice of services and charges so the patient can seek reimbursement from their home province.

Patient Information:

  • Province: Two letter code representing the province of the patient’s registration
  • Registration Number: Assigned to the patient in his or her province of residence (may be up to 12 characters without any spaces or special characters)
  • Date of Birth: YYYYMMDD format (e.g., 19491225)
  • Patient’s Surname: Up to 13 characters of the patient’s last name
  • Payment Program: Must be RMB (if unable to change this field, physicians should contact their software provider for instructions)
  • Payee: Must be P for pay provider
  • Patient’s First Name: Up to six characters of the patient’s first name
  • Sex: 1 (male) or 2 (female)

Participation in the Reciprocal Medical Billing System (RMBS) is voluntary; however, participation is recommended when an OOP resident presents a valid health card from their jurisdiction of residence. This ensures payment under the Ontario Schedule of Benefits for Physician Services rate.

Other options for payment include:

  • Submitting a paper claim directly to the patient’s home plan (e.g., QC); or
  • Charging the patient directly (e.g., those with an expired health card)

Physicians who do not submit through the RMBS and who bill the patient’s home ministry or who bill the patient directly can use the standard “Out of Province Claim for Physician Services” form (0000-80).

If payment is received directly from a patient, in addition to a detailed invoice of the services provided, (e.g., the form above or some other invoice listing the services and charges) please ensure the patient is provided with proof of payment; so that they can seek reimbursement from their home plan.

The following services are excluded from RMB and should be billed directly to the non-resident patient (or to the non-resident’s home province/territory if prior approval has been granted by the home province/territory):

  • Surgery for alteration of appearance (cosmetic surgery)
  • Sex reassignment surgery
  • Surgery for reversal of sterilization
  • Routine periodic health examinations including routine eye examinations
  • Lithotripsy for gall bladder stones
  • Treatment of port wine stains on other than the face or neck, regardless of the mode of treatment
  • Acupuncture, acupressure, transcutaneous electro-nerve stimulation (TENS), moxibustion, biofeedback, hypnotherapy
  • Services to persons covered by other agencies (e.g., Armed Forces, Workplace Safety and Insurance Board, Department of Veterans’ Affairs, Correctional Services of Canada [Federal penitentiaries])
  • Services requested by a third party
  • Team conference(s)
  • Genetic screening and other genetic investigation, including DNA probes
  • Procedures still in the experimental/developmental phase
  • Anaesthetic services and surgical assistant services associated with all of the above
  • Services required by the Ministry of Community and Social Services and the Ministry of Attorney General or the Solicitor General
  • PET scans and Gamma Knife Radiosurgery
  • Telemedicine services

Note: The patient may be eligible for reimbursement by his or her own provincial/territorial plan.

Coding Requirements

Fee Schedule Codes are located in the ministry Schedule of Benefits for Physician Services. In addition, the following information will assist with the submission of claims:

Cut-Off Date for Claims Submission

The ministry operates on a monthly processing cycle. Submissions received by the 18th of the month will typically be processed for approval the following month. When the 18th falls on a weekend or holiday, the deadline will be extended to the next business day. MCEDT submissions received after the 18th may not be approved until the next monthly processing cycle (i.e. submissions received on Nov 18th will appear on the December RA, submissions received after Nov 18th may not appear until the January RA).

Claims must contain complete, valid and accurate information in order to be processed on time. Claims requiring internal review by ministry staff may have payment delayed.

The ministry recommends daily or weekly submissions of claims to ensure timely adjudication of claims files and to aid in the subsequent reconciliation of rejected claims.

Resubmission of Unpaid Claims

In accordance with regulation under the HIA, all claims must be submitted within six months of the date of service. This includes original and resubmitted claims (i.e. corrected). Claims submitted more than six months following the date of service are termed “stale dated” claims.

Claims Requiring Documentation

The manual review indicator is a field in your medical claims billing software which allows you to inform the ministry that special attention such as supporting documentation is required to process a specific claim.

Supporting documentation should be electronically submitted to the ministry using eSubmit or faxed to your OHIP claims processing office when the claim is submitted:

Supporting documentation may include documents such as an operative report/clinical notes, or a “Claims Flagged for Manual Review” form (2404-84). The reasons for submitting this form as supporting documentation are listed on the form. This form is not required if using eSubmit to supply supporting documentation to the ministry.

A “Request for Approval of Payment for Proposed Surgery” form (0691-84) is another supporting document; however, it is to be submitted to your claims processing office prior to the service being rendered.

Find a list of available OHIP forms.

Special Notes about “Claims Flagged for Manual Review” form

Do not use the “Claims Flagged for Manual Review” form for:

Use this form for:

  • duplicate service code claimed for the same date, different time
  • claim resubmitted with a requested operative report
  • statement from operating surgeon substantiating 2 surgical assistants
  • suppression of service verification
  • specific services which you want to be manually reviewed by the ministry
  • out-of-province referring provider information (e.g. name and address)
  • statement from operating surgeon to substantiate claim for M400B assistant fee when no basic fee is listed
  • anesthetic or assistant claims where total units exceed “99”-see Data Link (93-004) Divisional Communication, August 1993

A “Request for Approval of Payment for Proposed Surgery” form (0691-84) is another supporting document; however, it is to be faxed to your claims processing office prior to the service being rendered.

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Reports

The following reports are sent electronically from the ministry. Only reports applicable to your practice will be sent to you. All reports must be retrieved (downloaded) for review or appropriate action.

File Reject Message

A File Reject Message notifies you if the ministry has rejected an entire claims file. This report is usually sent within a few hours of the ministry receiving your claims submission.

Batch Edit Report

A Batch Edit Report notifies you of the acceptance or rejection of claims batches. This report is usually sent within 24 hours of the ministry receiving your claims submission. If claims are uploaded on a weekend, holiday or at month end, the Batch Edit Report is delivered on the next claims processing day.

Claims Error Report

Claims submitted may be rejected for a variety of error conditions. Each file submission processed by the ministry may generate an Error Report (if applicable), therefore, several error reports may be received throughout the month based on the frequency of claims submissions. Claims rejected to an Error Report are automatically deleted from the payment stream. Rejected claims must be corrected and resubmitted to be processed for payment.

A Claims Error Report provides a list of rejected claims and the appropriate error codes or error report message for each claim. Error codes may be reported at the header level of a claim and/or at the item level. Rejected claims may have more than one error code or error report message assigned (refer to Error Codes or Error Report Messages for further detailed explanation of the possible error codes).

The Error Code is a three-character alpha/numeric code. The first character is an alpha and denotes the type of reject as follows:

  • V-Validity Error (applies to HCP/WCB/RMB payment programs)
  • A-Assessment Error (applies to HCP/WCB/RMB payment programs)
  • E-Eligibility Error (applies to HCP/WCB/RMB payment programs)
  • R-Reciprocal Medical Billing (RMB) Specific Errors
  • T-Telemedicine Error (applies to HCP payment programs)

A rejected claims item may be internally re-routed to the Error Report by the ministry and will include an error report message. The error report message is generated to provide more detailed information as to why the claim is being returned. Error report messages appear directly below the related claim item (refer to Error Report Messages PDF Document).

Rejected claims shown on the Error Reports are returned during the processing month. The corrected information should be resubmitted immediately. If the resubmitted information is received prior to the 18th of the same month, the claim can be processed for payment in the same billing cycle. Claims must be resubmitted within six months of the date of service to avoid being rejected as a stale dated claim.

Claims Error Reports should be retained on file in your office to assist in monthly payment reconciliations. If claims are not approved for payment on your monthly Remittance Advice Report (RA), then check your Error Report for that month to determine if the claim was rejected and needs to be submitted again.

A Claims Error Report is usually sent within 48 hours of claims file submission. If claims are uploaded on a weekend, holiday or at month end, the Error Report is delivered on the next claims processing day.

Split Claims Error Report

The Split Error Report is only available to physicians affiliated with a primary care group.

This report summarizes an individual physician’s rejected claims that were submitted under the group number. A list of rejected claims and the appropriate error codes for each claim will appear on the report (refer to Error Codes PDF document).

Remittance Advice Report (RA)

An RA is a monthly statement of approved claims. You will receive your RA between the 5th and 7th of the month following the successful submission and processing of your claims.

Your RA is issued before you receive your payment on the 15th business day of each month.

Group RA Split/Extract

The group RA Split/Extract is only available to individual physicians within a Family Health Network (FHN) for reconciliation of their own claims.

The FHN primary care groups operate over a wide area of separate physical locations and every physician in a FHN may have a different billing package and submit claims from individual locations. The RA Split/Extract contains a FHN physician’s own claim details only.

Overnight Batch Eligibility Checking (OBEC) Response File

Overnight Batch Eligibility Checking (OBEC) is a Health Card Validation (HCV) method that enables health care professionals to verify the eligibility of a patient’s health number/version code before a health service is provided. A formatted file of health numbers/version codes can be sent to the ministry for processing and eligibility is verified against the ministry’s database based on the date the file is submitted.

OBEC files received by the ministry by 4:00 pm are processed overnight and the response file will be sent to your MCEDT account by 7:00 am the following morning.

Governance Reports

Governance Reports are only sent to groups that provide specialty services in a hospital or an academic health sciences centre within specific communities. The following reports are generated monthly and sent to the MCEDT account for the governance at time of registration with the ministry.

  • Academic Health Science Centre (AHSC) Governance Reports
  • Northern Specialist Alternate Payment Program Governance Reports

Primary Care Reports

The following enrolment/consent reports are only sent to primary care physicians.

Enrolment/Consent Outside Use Report

Outside Use is a core service that is provided to enrolled patients by any family physician who is not affiliated with the patient’s primary care group. The report includes outside use details for each physician within a specific primary care group to assist in the calculation of their Access Bonus payment.

Enrolment/Consent Patient Summary Report

This report is a summary of patient enrolment activity to date. The report includes total number of members, breaks down total numbers into member status (e.g. assigned, enrolled, pre-members) and unconfirmed total.

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Reconciliation and Payment

Your RA may contain codes that indicate when a service has been reduced or disallowed because of medical rules which control the payment of claims (refer to Remittance Advice Explanatory Codes PDF document).

Inquiries on your RA should be submitted within four months from the date of the RA on which the claim appears.

Information updates will be transmitted via the message facility of the monthly RA. It is important that your reconciliation software allows you to read information displayed in the RA message facility. Please read all communications to ensure you are up-to-date on topics relevant to your practice. Copies of communications should be kept for reference.

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Inquiries

  • Inquiries regarding underpayments must be made within four months of the date of the RA on which the payment appears and should include information/documentation to support the inquiry/request.
  • Inquiries can be submitted electronically to the ministry using eSubmit; or mailed/faxed to your claims processing office using a “Remittance Advice Inquiry” form (0918-84). The ministry may determine that the decision is its final payment decision at any stage of the inquiry process.
  • If the payment decision has not been identified as final, the physician may continue the inquiry process by providing new information or documentation in a timely manner to support the ministry’s review of the claim(s). This may continue so long as there is meaningful dialogue between the physician and the ministry (i.e., new documentation/information is provided). A new RAI should not be submitted.
  • Where a physician disagrees with the ministry’s final payment decision, a hearing by the Physician Payment Review Board may be requested. This request must be made within 20 business days from the time the response is sent by the ministry or a payment decision letter from the ministry (whichever is later).
  • Remittance Advice Inquiry (RAI) forms will only be returned if a request has been partially adjusted, denied or if further information is required. The returned Remittance Advice Inquiry form will be returned with an explanation to the provider or billing agent. For providers submitting claims via Medical Claims Electronic Data Transfer (MCEDT), the form will be returned electronically. In MCEDT, Select the option to download reports. These documents are displayed with a File Type of “General Communication”.

Note: inquiries related to overpayments or correcting a claim (e.g., incorrect health number, service date, diagnostic code, service not provided) can be submitted using eSubmit or on an RAI form. These should be submitted within four months of the date of the RA; however, they may still be considered after this time.

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Province and Territory Codes

Review the Province and Territory Codes as a PDF document.

Error Report Explanatory Codes

Review the Error Report Explanatory Codes as a PDF document.

Error Report Rejection Conditions

Review the Error Report Rejection Conditions as a PDF document.

Remittance Advice Explanatory Codes

Review the Remittance Advice Explanatory Codes as a PDF document.

Specialty Codes

Review the Specialty Codes as a PDF document.

Diagnostic Codes

Review the Diagnostic Codes as a PDF document.

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For More Information

Call ServiceOntario, Infoline at:
1–866–532–3161 (Toll–free)
In Toronto, (416) 314–5518
TTY 1–800–387–5559.
In Toronto, TTY (416)327–4282
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