The possible outcomes for OHIP claims

What outcomes can I expect for my claim submission to OHIP?

There are four possible outcomes or scenarios:

The Four Scenarios

Most OHIP claims follow the ideal billing flow shown in the rightmost flow chart (Best Scenario).

In the "Best Scenario" a Claim is entered and saved to the UNSUBMITTED status, then submitted to OHIP, thus placing it in the SUBMITTED status. Finally, OHIP’s Remittance Advice Report (RA) moves the claim from the Submitted status to the PAID status.

Claims are sometimes rejected by OHIP. The left-most flow chart represents these (OK…No problem Scenario).

In the "OK…No problem Scenario" the user fixes a Rejected Claim and saves it to the UNSUBMITTED status. The claim is re-submitted to OHIP, thus placing it in the SUBMITTED status. Finally, OHIP’s RA moves the claim from the Submitted status to the PAID.

A third scenario (Aha, My Mistake Scenario) represents Rejected claims that do not qualify for payment by OHIP.

Examples include previous claims, specific procedures with limited eligibility and service codes that cannot be billed in combination. In this scenario, the user moves the claim from the SUBMITTED status to the CLOSED status.

The last possible scenario is the unenviable “Feeling Lost Scenario.”

The “Feeling Lost Scenario” involves claims that seem not to have triggered a response by OHIP. These claims were neither rejected nor paid; they seem to have been “ignored” by OHIP or “forgotten” by the user. Most of these claims need to be moved from the status of SUBMITTED to UNSUBMITTED. UNSUBMITTED claims will then be re-submitted to OHIP.

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