In Ontario, healthcare providers must submit claims to the Ontario Health Insurance Plan (OHIP) within three months from the date a service is rendered. Claims submitted after this period are considered “stale-dated” and may be refused payment by the Ministry of Health (MOH).
Extenuating Circumstances
The MOH may consider payment for stale-dated claims if providers can demonstrate that extenuating circumstances prevented timely submission. Extenuating circumstances are defined as extraordinary and unforeseen events beyond the provider’s control that hindered the submission process.
Resubmission of Rejected Claims
If a claim initially submitted within the three-month period is rejected and becomes stale-dated upon resubmission, providers should:
- Correct Errors and Resubmit: Address all errors and resubmit the claim(s) in a single stale-dated claim file via the Medical Claims Electronic Data Transfer (MCEDT) system.
- Notify Claims Services Branch: Send an email to ClaimsManagement@ontario.ca with the following information:
- Provider’s full name, address, phone number, six-digit OHIP billing number, and/or four-digit group number.
- A list of outstanding claims being resubmitted, including the patient’s health number, date of service, and fee schedule code(s).
- Confirmation of the stale-dated claim file upload, including the file number and date of upload.
- Corresponding Error Reports indicating that the original submission was within the three-month period.
Separate submissions are required for each physician or group, depending on how claims are submitted. Requests for different physicians should not be combined in one email.
First Submission of a Stale-Dated Claim
For claims that have never been submitted and are now stale-dated, providers must:
- Send a letter to ClaimsManagement@ontario.ca including:
- Provider’s full name, address, phone number, six-digit OHIP billing number, and/or four-digit group number.
- A list of the stale-dated claim(s) with the patient’s health number, fee schedule code(s), and date(s) of service.
- The extenuating reasons that prevented timely submission.
- Signature of the provider and/or group representative (signatures from billing agents or administrative support staff are not accepted).
As with resubmissions, separate submissions are required for each physician or group. Do not combine requests for different physicians in one email.
Recent Changes to Submission Periods
Effective April 1, 2023, the claims submission period for OHIP fee-for-service insured and related services was reduced from six months to three months from the date a service is rendered in Ontario. This change applies to services rendered on or after April 1, 2023. Services rendered prior to this date retain the six-month submission period.
Best Practices
To ensure timely payment and avoid complications with stale-dated claims, providers are encouraged to:
- Submit all claims promptly within the three-month window.
- Regularly review Error Reports and address any issues immediately.
- Maintain thorough documentation to support any claims of extenuating circumstances.
By adhering to these guidelines, healthcare providers can navigate the OHIP claims process more effectively and minimize the risk of claim denials due to late submissions.
