Bulletin 231001 — Update: Three-month submission timeframe for in-province claims
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 Billing Software Specifications
Written by: Claims Services Branch; Health Programs and Delivery Division
Date issued: October 4, 2023
Bulletin Number: 231001
Claims submission period
As per INFOBulletins 220907, 221206, 230301, and 230402, the claims submission period for OHIP fee-for-service insured and related services is now three months from the date a service is rendered in Ontario.
This applies to any services rendered on or after April 1, 2023.
Services rendered prior to April 1, 2023 continue to have six months for submission.
The ministry encourages all providers to submit claims early and regularly with appropriate supporting documentation to avoid claims becoming stale dated.
VJ7 – stale dated claim
Claims submitted three months after the service date will be rejected to the Claims Error Report with error condition ‘VJ7 - Stale dated claim’. Claims that are stale dated will not be accepted for payment unless there are extenuating circumstances, or the claim has been previously rejected to the Claims Error Report within 3 months of the date of service.
Update to the stale date review process
The ministry’s process for reviewing stale-dated claims has been updated to allow claims submitted within three months of the date of service that reject to an error report to be corrected and resubmitted after the three-month claims submission timeframe. This process only applies to claims for services rendered on or after April 1, 2023.
In such cases, the provider must submit supporting documentation, including a copy of their error report and claim identifying data, to demonstrate that the original claim was submitted within 3 months.
Resubmission of a previously rejected claim that is now stale dated
- Correct all errors and resubmit the claim(s) in one single stale dated claim file via the Medical Claims Electronic Data Transfer (MCEDT). You can do this by selecting "file upload" and then the "stale dated claim file" option in the drop-down menu on the GO Secure website, or by using the appropriate option to upload a stale dated claim file in your billing software.
- Send an email to ClaimsManagement@ontario.ca including all of the following:
- Six-digit OHIP billing number and/or four-digit group number. Separate your request by physician and group. Do not send requests for different physicians in one email.
- A list of outstanding claims being resubmitted.
- Confirmation that the stale-dated claim file has been uploaded.
- Corresponding Error Reports for all claims being resubmitted for stale date processing.
Claims should be resubmitted as soon as possible after the rejection date to ensure payment of eligible claims.
Submission of stale dated claims not previously submitted
For stale dated claims that were not previously submitted within 3 months of the service date, the process is as follows.
Physicians or group representatives should send a letter on letterhead to ClaimsManagement@ontario.ca with the following information:
- The provider’s OHIP billing number and/or group number. Please note separate submissions are required for each physician or group. Do not send multiple requests in one email.
- A list of the stale dated claim(s) including the patient’s health number, fee schedule code(s) and service date(s).
- Extenuating reasons that prevented the claim(s) from being submitted within the three-month submission timeframe.
- Signature of the provider and/or group representative (billing agent and secretary signatures will not be accepted).
The stale dated claim approval request submission will be reviewed and a response letter will be sent to the provider.
VJ7; Claims submission window; six months; three months; submission timeframe; remittance advice inquiry; RAI; stale-date; stale date; 3 months; 6 months
Do you have questions about this INFOBulletin? Email the Service Support Contact Centre or call 1-800-262-6524. Hours of operation: 8:00 a.m. to 5:00 p.m. Eastern Monday to Friday, except holidays.