Bulletin 221104 — Electronic Claim Submission for Third Party Billers
Registered Third Party Billing Agencies to submit Out-of-Country Claims electronically
To: MCEDT Software Vendors
Category: Billing software specifications
Written by: Claim Services Branch, Health Programs and Delivery Division
Date issued: November 18, 2022
Electronic Third Party Out-Of-Country claim submissions
The Ministry of Health reinstated the Out-of-Country (OOC) Travellers Program for Ontarians travelling outside of Canada retroactive to January 1, 2020.
This program is for treatment of medical conditions that are acute and unexpected, arose while outside the country, and require immediate treatment.
Registered Third Party Billing Agencies submit a high volume of Out-Of-Country claims to the Ministry of Health on behalf of their eligible Ontarian patients. The ministry has requested Registered Third Party Billing Agencies to electronically submit claims for Out-Of-Country services through the Medical Claims Electronic Data Transfer (MCEDT).
Unique claim submission requirements
Registered Third Party Billing Agencies have requirements for submission that differ from in-province submitters as follows:
- Registered Third Party Billing Agencies have 12 months from the date of service to submit a claim for payment. Claims submitted within 12 months are accepted and are not considered a stale-date claim file.
- If a patient was billed a greater or lesser amount than the OHIP value for an insured service provided out-of-country, the claim must reflect the fee billed amount the patient was charged. Registered Third Party Billing Agencies must be able to modify the “fee billed” amount they are requesting for services for audit and reconciliation purposes.
- There are select fee schedule codes (FSCs) provided to Registered Third Party Billing Agencies directly by the ministry for billing, which are not included in the Schedule of Benefits for Physician Services (Schedule). In addition to the FSCs within the Schedule, Registered Third Party Billing Agencies must be able to input FSCs not included in the Schedule.
RTPBA; Registered Third Party Billing Agency; Out of Country; OOC; Claims; MCEDT; Vendor; Software