Rules regarding claim submission periods and stale-dated claims

Education and Prevention Committee Billing Briefs

Education and Prevention Committee (EPC) Billing Briefs are prepared jointly by the Ministry of Health (MOH) and the Ontario Medical Association (OMA) to provide general advice and guidance to physicians on billing matters.

Category: All physicians; billing clerks; hospitals and facilities     
Date Issued: January 7, 2025

Claim submission period

The claim submission period is the maximum timeframe from the service date to when the claim submitted will be accepted and processed for payment through the OHIP claims system (if computerized payment requirements are met).

As of April 1, 2023, the claim submission period is three months from the date a service is rendered for all OHIP insured physician services provided in Ontario. This timeframe also applies to OHIP insured services for other health care providers and organizations including:

• Dentists
• Podiatrists
• Optometrists
• Nurses with extended class
• Hospitals and other facilities
• Community laboratories
• Integrated community health services centres (ICHSCs)

Note that the three-month limit applies to any service rendered on or after April 1, 2023. Claims for in-province services rendered before this date previously had a six-month claim submission period.

Claim submissions after the three-month period

A claim that is not submitted within the prescribed timeframe (a claim submitted more than three months from the service date) is referred to as a “stale-dated claim.” As set out in the Health Insurance Act, the MOH may refuse to pay for an OHIP insured service if the claim is stale-dated.

The MOH may accept a stale-dated claim for consideration of payment if the provider can demonstrate that extenuating circumstances prevented the submission of the claim within three months from the service date.

Extenuating circumstances

The MOH considers extenuating circumstances to be extraordinary and unusual events that arise suddenly and unexpectedly, which are beyond the control of the provider, are unforeseen and cannot be reasonably anticipated, thereby affecting the provider’s ability to submit their claim to OHIP within the claim submission period.

Claims originally submitted within the three-month period which require correction or additional information

Some claims that are submitted within three months from the service date may be rejected because they require correction or additional information. The physician will be notified of the rejection when the claim is returned to the physician’s Error Report.

To be paid, these claims must be resubmitted with correction(s), with the required supporting documentation (example: operative report, other medical records, letter of explanation, etc.) using the process outlined below.

Physicians are encouraged to resubmit claims promptly to facilitate review and resolution.

How to submit a stale-date claim for review

Claims resubmission

If claims that were originally submitted within the three-month period were returned to the Error Report, resubmit using the two following steps:

1. Physicians or group representatives must correct all errors and resubmit the claim(s) in a single stale-dated claim file via the Medical Claims Electronic Data Transfer (MCEDT).
   • Do this by selecting "file upload" and then the "stale-dated claim file" option in the drop-down menu on the OPS BPS Secure website, or by using the appropriate option to upload a stale-dated claim file in your billing software, and,
2. Send an email to ClaimsManagement@ontario.ca including all of the following:
   • The 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. This must include the patient’s health number, date of service, and fee schedule code(s).
   • Confirmation that the stale-dated claim file has been uploaded, by including the file number and date of upload.
   • Corresponding Error Reports which reflect that the original submission made to OHIP was within the three-month period for all claims being resubmitted for processing.

Note that separate submissions are required for each physician or group, dependent on how claims are submitted. Please do not send requests for different physicians in one email.

First submission of a stale-dated claim

If the claims have never been submitted and are now stale-dated, submit using the following process:

Physicians or group representatives must send a letter to ClaimsManagement@ontario.ca including all of the following information:

• The 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) including the patient’s health number, fee Schedule code(s) and date(s) of service.
• The extenuating reasons that prevented the claim(s) from being submitted to OHIP within the three-month submission period.
• Signature of the provider and/or group representative (billing agent and administrative support/billing clerk signatures will not be accepted).

Note that separate submissions are required for each physician or group, dependent on how claims are submitted. Please do not send requests for different physicians in one email.

Stale-date claim inquiries

Please call 1-800-262-6524 for questions regarding how to submit stale-dated claims.

Examples

Example 1a: Claim submitted within three months of the service date, returned to Error Report, and then resubmitted (still within three months of the service date)

Dr. Jones submits a claim one month after the service date; however, the claim is returned to the Error Report as the health card version code that was provided on the claim is incorrect. Dr. Jones resubmits the claim with the correct version code two months after the service date.

Will Dr. Jones’ claim be accepted and processed for payment?

Explanation:

• As the original submission and resubmission of the claim were completed within three months of the service date, the resubmission will be accepted and processed for payment.
• Additional information regarding health card validation can be found at the following link: Registration of Ontario Health Insurance coverage | Resources for Physicians

Example 1b: Claim submitted within three months of the service date, returned to Error Report, and then resubmitted more than three months after the service date

Using the same scenario described in example 1a above, but instead Dr. Jones resubmits the claim with the correct version code four months after the service date.

Will Dr. Jones’ claim be accepted and processed for payment?

Explanation:

• As the original claim was submitted within three months of the service date, Dr. Jones may resubmit the claim using the steps outlined within the claims resubmission process above (upload a stale-dated claim file and send an email with all required information to ClaimsManagement@ontario.ca).
• Provided that this process is followed, and all errors have been corrected, the MOH will accept the claim and process for payment.

Additional information:

• The ministry encourages providers to ask for a patient's most recent health card and to validate the health card each time the patient visits. This will reduce additional administration time for providers associated with rejected claims due to incorrect version code submission and patient ineligibility.
• The ministry offers several automated Health Card Validation services to assist providers in determining a patient's eligibility and the validity of an Ontario health card status at the time a service is rendered.
• Registration of Ontario Health Insurance coverage | Resources for Physicians

Example 2: Newborn-related claim submitted within three months of the service date, returned to Error Report (Error: Health number not registered with the Ministry of Health), and resubmitted more than three months after the service date

Dr. Culligan is called to assess a newborn child and submits the claim within three months of the service date; however, the child’s Pre-Assigned Health Number (PAHN) is not registered at ServiceOntario. As a result, Dr. Culligan’s claim is returned to the Error Report with explanation – Health Number is not registered with MOH.

Following this, Dr. Culligan’s office is able to obtain the child’s updated health card information (example, from the child’s parents).

Will Dr. Culligan’s claim be accepted and processed for payment?

Explanation:

• As the original claim was submitted within three months of the service date, Dr. Culligan may resubmit the claim using the steps outlined within the claims resubmission process above (upload a stale-dated claim file and send an email with all required information to ClaimsManagement@ontario.ca).
• Provided that this process is followed, and all errors have been corrected, the MOH will accept the claim and process for payment.

Additional information:

• If Dr. Culligan’s office were unable to obtain the child’s updated health card information, no claim for insured services would be payable.
• If Dr. Culligan determines that the child does not have a valid Ontario health card, the services provided are not insured by OHIP and may be billed to the patient/family.
• The Pre-Assigned Health Number (PAHN) is the number pre-printed on the Ontario Health Coverage Infant registration form which is provided to parents by hospital staff or a registered midwife after a baby is born. This form must be completed and submitted to OHIP for the baby’s OHIP number to be registered and activated.
• Additional information regarding OHIP for babies can be found at the following link: Apply for OHIP and get a health card

Example 3: Claim submitted within three months of the service date, returned to Error Report, and then resubmitted more than three months after the service date with requested documents

Dr. Soleil submits a complex surgical claim within three months of the service date but does not upload the required operative report or supporting documents. The claim is returned to Dr. Soleil’s Error Report requesting resubmission of the claim along with the operative report/supporting documents.

Four months after the service date Dr. Soleil discovers the claim was returned to the Error Report.

Will Dr. Soleil’s claim be accepted and processed for payment?

Explanation:

• As the original claim was submitted within three months of the service date, Dr. Soleil may resubmit the claim using the steps outlined within the claims resubmission process above (upload a stale-dated claim file and send an email with all required information to ClaimsManagement@ontario.ca).
• Provided that this process is followed, and all errors have been corrected, the MOH will accept the claim and process for payment.

Example 4: Claim submitted more than three months after the service date (claim now considered stale-dated) because of a patient eligibility issue

Dr. Revah renders an OHIP insured service to a patient; however, at the time of the service, the patient is unable to present a valid Health Number/OHIP card and Dr. Revah bills the patient directly for the service(s) provided.

The patient returns to Dr. Revah four months later with a letter from the Ontario government proving OHIP coverage, including coverage on the date that the above noted service was rendered, and requests reimbursement from Dr. Revah.

Will Dr. Revah’s claim be accepted and processed for payment?

Explanation:

• As the original claim was not submitted within three months of the service date, Dr. Revah may submit the claim using the steps outlined within the first submission of a stale-dated claim process above.
• Dr. Revah must include a copy of the letter issued by the Ontario government confirming OHIP eligibility.
• In this example, the claim is reviewed by the ministry, a decision is made that this represents an extenuating circumstance, and a decision letter will be provided to the physician confirming that the request for extenuating circumstances has been accepted along with instruction for submission of the claim(s). Each request for payment of stale-dated claims due to extenuating circumstance will be reviewed on a case-by-case basis.

Additional information:

• In this scenario, the patient is responsible for providing a letter which confirms their OHIP coverage from ServiceOntario and/or the Ministry of Health.
• As patients cannot be charged for OHIP insured services if eligible, Dr. Revah must reimburse the patient in full once OHIP eligibility is demonstrated.

Example 5: Claim submitted more than three months after the service date (claim now considered stale-dated) with an extenuating circumstance

Dr. Duster’s office experiences water damage due to a burst pipe, causing destruction of computer equipment with claims for OHIP services that have not been submitted. By the time the situation is resolved, and Dr. Duster submits the claims, some claims have exceeded the three-month submission period.

Will Dr. Duster’s claims be accepted and processed for payment?

Explanation:

• The MOH considers extenuating circumstances to be extraordinary and unusual events that arise suddenly and unexpectedly, which are beyond the control of the provider, are unforeseen and cannot be reasonably anticipated, thereby affecting the provider’s ability to submit their claim to OHIP within the claim submission period.
• As the original claims were not submitted within three months of the service date, Dr. Duster may submit the claims using the steps outlined within the first submission of a stale-dated claim process above.
• Dr. Duster must include documents verifying the extenuating circumstance, in this case for example, a copy of the insurance claim.
• In this example, the claim is reviewed by the ministry, a decision is made that this represents an extenuating circumstance, and a decision letter will be provided to the physician confirming that the request for extenuating circumstances has been accepted along with instruction for submission of the claim(s). Each request for payment of stale-dated claims due to extenuating circumstance will be reviewed on a case-by-case basis.

Example 6: Claims submitted more than three months after the service date (claims now considered stale-dated) without an extenuating circumstance

Dr. Neill is a family physician who works in a walk-in clinic once a week. Dr. Neill becomes concerned that some claims have not been paid and discovers that the office billing clerk misplaced a folder with paperwork and failed to submit 20 claims five months ago.

Will Dr. Neill’s claims be accepted and processed for payment?

Explanation:

• These claims have not been submitted within three months of the date the insured services were provided and are now stale-dated.
• Administrative or operational errors occurring within a physician’s office would not be considered extenuating circumstances; therefore, the claims will not be accepted or processed for payment.

Example 7: Claims submitted more than three months after the service date (claims now considered stale-dated) with an extenuating circumstance

Dr. Parson experiences a serious health issue requiring urgent hospitalization, several procedures, and a four-month medical leave from practice. Dr. Parson does not submit all claims for services provided the week prior to the medical leave until returning to practice four months later. When submitted, these claims have exceeded the three-month submission period.

Will Dr. Parson’s claims be accepted and processed for payment?

Explanation:

• The MOH considers extenuating circumstances to be extraordinary and unusual events that arise suddenly and unexpectedly, which are beyond the control of the provider, are unforeseen and cannot be reasonably anticipated, thereby affecting the provider’s ability to submit their claim to OHIP within the claim submission period.
• As the original claims were not submitted within three months of the service date, Dr. Jones may submit the claims using the first submission of a stale-dated claim process above.
• In this case, documentation supporting that a serious illness has occurred which prevented Dr. Parson from performing clinical activities for an extended period will be required and must be included in the request.
• In this example, the claim is reviewed by the ministry, a decision is made that this represents an extenuating circumstance, and a decision letter will be provided to the physician confirming that the request for extenuating circumstances has been accepted along with instruction for submission of the claim(s). Each request for payment of stale-dated claims due to extenuating circumstance will be reviewed on a case-by-case basis.

Keywords/Tags

OHIP; claims submission; billing; stale-date; stale date

More Information

Bulletin 220907 — Claims Submission Timeframe for In-Province Accounts

Bulletin 221206 — Reminder: Claims Submission Timeframe for In-Province Accounts

Bulletin 230301 — Reminder: claim submission timeframe for in-province accounts

Bulletin 230402 — Update: Claim Submission Timeframe for In-Province Accounts

Bulletin 231001 — Update: Three-month submission timeframe for in-province claims

Contact Information

If you have stale-dated claim submission inquiries, please contact the Service Support Contact Centre (SSCC) at 1-800-262-6524.

To provide feedback on EPC Billing Briefs, or to suggest topics for future EPC Billing Briefs, send an email to the attention of the joint Ministry of Health/OMA Education and Prevention Committee.

The Ministry of Health (MOH) and the Ontario Medical Association (OMA) have jointly prepared this educational resource to provide general advice and guidance to physicians on specific billing matters.

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Note: This document is technical in nature and is available in English only due to its limited targeted audience. This publication has been exempted from translation under the French Language Services Act. For questions or support regarding this document, please contact the Service Support Contact Centre (SSCC) by email or by calling 1-800-262-6524.

Remarque : Ce document est de nature technique et est disponible en anglais uniquement en raison de son public cible limité. Ce document a été exempté de la traduction en vertu de la Loi sur les services en français. Pour toute question ou de l’aide concernant ce document, veuillez contacter Les Services de renseignements, Centre de contact pour le soutien des services par courriel ou en téléphonant le 1-800-262-6524.