bulletin

Bulletin Number
        4305
Date
        February 27, 1998
Direct inquiries to
         Ministry of Health
         Processing Office

(address below)
Distribution
        Physicians, Hospitals, Clinics, and Laboratories
Subject      GOOD FAITH CLAIMS PAYMENT POLICY UPDATE
Effective March 1, 1998 (see Bulletin #4303), the Ministry will not make payment in good faith for claims submitted for services rendered when the eligibility of an Ontario Health Card holder is not in effect or for services rendered in a hospital setting when the Health Number has a missing or incorrect version code.

The following information and guidelines will assist you with the implementation of this policy.

  • Validate the most recent patient’s Health Card at each visit and update your patient records with any changes (validation will give you access to the Ministry’s database to confirm eligibility and Health Card status)
    1. If the Health Card is not available, advise patients to carry and present their most recent Health Card every time they require services. A Ministry advertisement campaign reinforces this message to the public.

    2. Refer back to the patient, to previous health records, or to a person accompanying the patient who may have a record of the Health Number and version code.
  • If validation indicates

    1. there is no eligibility and/or if you are not reasonably satisfied that the patient is eligible, the patient should be directed to a MOH office where eligibility will be assessed and applied retroactively, if appropriate. The patient may also be billed for the service, however, if billed, the patient is to be reimbursed in full by the provider upon the patient subsequently providing proof of eligibility to you. When correct information is received, submit the claim to the Ministry for payment.

    .../2

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