Claims Submission Ontario Health Insurance Program
Resource Manual for Physicians
 
4.16   Questions and Answers

What is the monthly cut-off for claims submission and when will I receive payment ?

Machine readable claims (diskettes or Electronic Data Transfer) received by the ministry by the 18th of the month will be processed for payment by the 15th of the following month. When the submission cut-off (18th) date falls on a weekend or holiday, the deadline will be extended to the next business day. EDT claims will be processed after the 18th where time and volumes permit.

My software program includes a field for "Manual Review Indicator".   What is it and when would I use it ?

For most claims, this field would be blank; however, if the claim requires special consideration (e.g., two identical services billed same day), a  Y  indicator should be entered in this field.   If  Y  is used, the claim will be flagged for internal manual reviewed and adjudication.

Supporting documentation must be sent to the ministry and must contain specific information so that it can be matched to the claim submission. The form Claims Flagged for Manual Review indicates the information that is required for claims submitted with a  Y  indicator. The supporting documentation may be submitted with your diskette/tape submission. If submitting on Electronic Data Transfer (EDT), the form can be faxed to your local ministry office.

When claims are submitted, how do I get notified of submission errors ?

For diskette/tape input, claim errors are returned to the provider on a Machine Readable Input Claims Error Report. Errors reported must be corrected and resubmitted in order for payment to be made. Error reports should be retained in order to track claims that may not appear on the next remittance advice.

For EDT claims submissions, a Batch Edit Report will be sent to acknowledge receipt of your claims file, usually within 24 hours of file transfer. An EDT Claims Error Report will be sent to you within 48 hours after file transfer.

When is a claim considered stale dated ?

Claims must be submitted within six months of the service date. Claims submitted more than six months after the service has been rendered will not be accepted for payment unless there are extenuating circumstances as defined by ministry policy.

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