How the OHIP Claims Submission Process Works

In Ontario, doctors submit "invoices" of who they saw and what they did to the ministry of health, who then reimburses them for the health care services provided through the Ontario Health Insurance Plan (OHIP).

Medical Claims Electronic Data Transfer (MC EDT)

These claims are submitted through the medical claims electronic data transfer (MC EDT) system.

The MC EDT system is essentially a secure web service that allows third-party software providers to submit claims to OHIP on your behalf. It's the framework on which Dr. Bill is built for processing billings in Ontario.

The MC EDT system allows:
• Secure user authentication;
• Designation to admin staff or third parties agents to submit and reconcile claims on your behalf;
• Electronic reports (Claims Error Reports, Remittance Advice Reports, etc).

The MC EDT system is up and running 24/7 (except a few short scheduled maintenance times each week). 

To register for MC EDT, follow these steps.

The Process of Submitting Claims

Depending on what kind of program you're using, whether a billing component of an EMR / CMS or billing software, the specific workflow of submitting claims may differ.

Ultimately though, the general process is similar: a doctor sees a patient, performs a service, then submits a claim to OHIP for payment.

In order to be paid out, a claim will need to include:

  • the patient's information (in order to make sure they're eligible for insurance coverage for that service)
  • the details of the service – which is done by including a diagnostic code and fee code.

OHIP Fee Codes

The ministry publishes the Schedule of Benefits for Physician Services, which outlines the various fee schedule codes that can be used to bill for health care services.

Each code corresponds to a specific service and dollar amount.

For example, if a GP sees a patient for a visit they may submit a claim with the fee code A005 (Consultation). This fee code has a value of $77.20, which is how much OHIP may reimburse the doctor for.

The ministry then determines whether to pay out the claim in full, in part, or none at all.

This process forms the basis of the fee-for-service model of physician remuneration in Canada.

Submission Deadlines

OHIP claim submissions run on a monthly cycle. All claims you submit until the 18th of each month will be processed for payment by the 15th of the next month. 

When the 18th falls on a weekend or holiday, the deadline will be on the next business day. Claims received after the 18th of the month might get processed by the end of the month.

Reports

Remittance Advice (RA) Report

The RA report is essentially your monthly report of claims that were approved and paid.

You'll get this report at the beginning of each month – usually between the 5th and 7th. (Payment will then be received for approved billings on the 15th business day).

Claims Error Report

Billing OHIP can result in having claims sent back with Claims Error Reports detailing various issues with submitted claims. 

Here is a list of error codes that you may see on your reports, along with a description of what the issue is: dr-bill.ca/ohip-billing-error-codes

Reconciliation and Payment

When a claim does get rejected or the payment is reduced, you can resubmit the claim and inquire to appeal the decision.

The Remittance Advice Inquiry form is used to inquire about these underpaid claims. This needs to be done within four months from the issue date of the RA report that detailed the claim in question.

Keep in mind that claims have to be submitted within six months of the original date of service.

Any billings submitted after that deadline will be rejected and become 'stale dated' claims.

How claim submission works on Dr. Bill

Dr. Bill is a platform used by over 700 Canadian physicians to manage their billing.

We offer a smartphone app that lets you take a picture of a patient label and submit your claims in a few taps. You can then review your submissions and manage rejections on the web.

Doctors use our system alongside their EMRs – submitting their billings as they work and never missing a claim again. Our team of in-house billing agents are also there to help.