Bulletin 221206 — Reminder: Claims Submission Timeframe for In-Province Accounts
Reminder: The Ministry of Health is changing the claims submission period for in-province accounts from six months to three months.
To: All Physicians, Hospitals, Community Laboratories, Independent Health Facilities, Optometrists, Hospital-based Dentists, Podiatrists, Nurse Practitioners; OHIP Billing Software Vendors
Category: Physician Services, Primary Health Care Services, Independent Health Facilities, Optometrist Services, Dentist Services, Podiatrist Services, Registered Nurse with Extended Class; Billing Software Specifications
Written by: Claims Services Branch; OHIP, Pharmaceuticals and Devices Division
Date issued: December 30, 2022
Change to the Claims Submission period
As per INFOBulletin 220907, the Ministry of Health (the ministry) is adjusting the claims submission period for OHIP fee-for-service insured and related services from six months to three months from the date a service is rendered in Ontario, effective April 1, 2023.
This change is outlined in the 2021-24 Physician Services Agreement.
The ministry is also implementing these claim submission timeframe adjustments for claim submissions from patients, other practitioners, community laboratories and independent health facilities.
Please note: this change will have no impact on claims for insured services rendered outside of the province of Ontario.
New “W3” explanatory code
Starting on the October 2022 Remittance Advice (RA), in order to assist providers during this transition, a new explanatory code ‘W3-Service date is older than 3 months’ will appear.
This will alert providers that a claim was submitted more than three months from the service date. The new explanatory code will assist providers for planning purposes by allowing the tracking of submission timelines well in advance of the effective date of this change.
Claims that receive the “W3” explanatory code will still be processed for payment.
Update to the Stale-Date review process
The ministry’s current process for reviewing stale-dated claims will also be updated to allow claims submitted within three months of the date of service that are rejected to a Claims Error Report to be corrected and resubmitted after the three month claims submission timeframe.
Further information on the revised stale-date process will be communicated at a future date to assist providers with this transition.
Update to the Remittance Advice Inquiries review process
To further assist providers with this transition, the submission period for Remittance Advice Inquiries will also be changed from the current maximum of four months from the date of the RA, to seven months from the date of the RA.
These changes will be implemented effective April 1, 2023, for services rendered on or after April 1, 2023.
Claims submission window; six months; three months; submission timeframe; remittance advice inquiry; RAI; stale-date; stale date; 3 months; 6 months