Starting Your Practice in Ontario: An OHIP Billing Guide for New Physicians
Starting your medical practice in Ontario involves more than seeing patients and submitting claims. Before you begin billing OHIP, there are several pieces that need to be in place, and once you start submitting claims, there is an ongoing process of reviewing errors, reconciling payments and following up on claims that were not paid as expected.
For physicians who are new to practice, understanding this process from the beginning can help prevent billing delays, rejected claims and missed revenue.
This guide provides an introduction to the OHIP billing process and some of the key things to consider as you establish your billing workflow.
1. Make sure your OHIP billing setup is in place
Before you can submit claims for insured physician services, you need an OHIP billing number.
The Ministry of Health requires physicians applying for an OHIP billing number to hold an appropriate Certificate of Registration, have an Ontario practice address, complete the Ministry's online application and provide banking information for direct payment. Once the application has been processed, the Ministry provides the physician's billing number and its effective date.
If you will be practising as part of a group, there may also be a group number associated with your billings. A group number is different from your personal OHIP billing number: it allows individual physicians' claims and payments to be associated with the registered group.
Physicians starting locum work should also be aware that the Ministry requires them to submit claims using their own OHIP billing number, rather than using the billing number of the physician they are replacing.
It is worth getting these arrangements sorted out before your first day of practice rather than discovering after you have accumulated several weeks of billing that something is missing or incorrectly set up.
2. Understand how your claims get to OHIP
Ontario physician claims are submitted electronically through the Ministry's Medical Claims Electronic Data Transfer (MCEDT) system.
MCEDT is the Ministry's secure electronic service for sending medical claim files and receiving billing reports and other information. Claims may be submitted using the Ministry's web interface or through compatible billing software that communicates with MCEDT.
Before setting up MCEDT access, your OHIP billing registration must first be completed. Once your billing number has been established and activated, the Ministry provides two Unique Identifiers required to register for MCEDT. The first corresponds to your OHIP billing number, while the second is a separate identifier assigned by the Ministry.
You can then use these identifiers to register for MCEDT through the Ontario government's secure online portal. Because you cannot complete MCEDT registration until this information has been issued, it is worth completing your OHIP billing-number application well before you expect to submit your first claims.
Set up your MCEDT account:
For most physicians, the important point is not the technical details of MCEDT.
It is understanding that billing is a two-way process:
You submit claims to the Ministry, and the Ministry sends information back about what happened to those claims.
Those returned reports are an essential part of billing. Submitting a claim is not the same thing as confirming that the claim was accepted and ultimately paid.
3. Decide how you are going to manage your billing
Before you begin practice, decide who will actually be responsible for the billing process.
Some physicians prefer to enter, submit and reconcile their own claims using billing software. Others want to remain involved in entering their billings but have assistance with rejections, follow-up and billing questions. Others prefer to have the billing process managed for them.
There isn't one approach that suits every physician. Your specialty, practice setting, billing volume, complexity of your claims and how much time you want to spend managing billing should all be considered.
Whichever approach you choose, it is important to know who is responsible for each part of the process — entering claims, submitting them, reviewing errors, reconciling payments and following up on unpaid or adjusted claims.
If someone else will be submitting claims or retrieving Ministry reports on your behalf, you may also need to designate them through MCEDT. The Ministry refers to an authorized person or organization that performs these functions on your behalf as a designee.
The exact arrangement depends on the billing service or software you use. If a billing service will be submitting claims and retrieving Ministry reports on your behalf, it will
require designee access. For software and apps, some require a designee while others allow you to retain direct control of your MCEDT account and connect your billing software to it.
Ultimately, the physician remains responsible for claims submitted to OHIP under their billing number and for ensuring that claims comply with the applicable billing requirements.
4. Capture the information you need at the time of service
Accurate billing starts before the claim is submitted.
Depending on the service being billed, a claim may require information such as the patient's health number and version code, date of service, appropriate fee schedule code, diagnostic information and other billing details required for that particular service. Consultation claims require the billing number of the referring physician, so this information should be captured when the consultation is received rather than tracked down later.
In office and clinic settings, one useful step is validating the patient's health card information at the time of service. The Ministry's Health Card Validation service can verify the patient's health number and version code and determine eligibility, helping reduce avoidable eligibility and incorrect-version-code claim errors.
This may be less practical in hospital-based practice, where physicians often rely on patient information supplied through the hospital rather than validating health cards themselves.
It is also much easier to resolve missing clinical or billing information while the encounter is recent than weeks later when you are trying to reconstruct what happened.
5. Learn the billing rules that apply to your practice
The OHIP Schedule of Benefits for Physician Services sets out the fees and requirements for payment of insured physician services. It is more than simply a list of fee codes and dollar amounts.
The correct billing can depend on factors such as the service performed, specialty, practice setting and the specific requirements attached to a fee schedule code.
Some services may also require additional information or supporting documentation before payment can be made.
For a physician new to billing, trying to learn the entire Schedule of Benefits at once is neither practical nor necessary. A better starting point is becoming familiar with the codes and rules that apply most frequently to your own specialty and practice setting, and knowing where to look when an unfamiliar situation arises.
The Ministry also publishes INFOBulletins and other billing guidance, so billing requirements should not be treated as something you learn once and never revisit.
6. Submit your claims regularly
Don't wait until the end of the month — or several months later — to submit your claims.
The Ministry recommends submitting claims daily or weekly. Regular submission allows problems to be identified sooner and makes rejected claims easier to correct and reconcile.
There is another important reason not to let billing accumulate.
For insured physician services provided in Ontario, the normal OHIP claim-submission period is three months from the date of service. A claim submitted after that period is considered stale-dated.
Submitting regularly can also help where more than one physician provides a service to the same patient on the same day. In some circumstances, a later claim may encounter a payment conflict because OHIP has already processed a similar service from another physician. Resolving these situations may require additional information or supporting documentation. Prompt submission can therefore save time as well as reduce the risk of claims becoming stale-dated.
There are processes under which certain stale-dated claims may still be considered. For example, the Ministry has a process for claims that were originally submitted within the three-month period but were returned on a Claims Error Report and require correction. The Ministry may also consider a claim that was never submitted within the three-month period where qualifying extenuating circumstances prevented timely submission.
These processes should not replace a regular billing routine. Submitting frequently gives you time to identify and resolve problems before submission deadlines become an issue.
7. Understand the monthly OHIP processing cycle
OHIP processes physician claims on a monthly cycle.
The Ministry identifies the 18th of the month as its regular claims-submission date for processing in the following month's cycle. When the 18th falls on a weekend or holiday, the date moves to the next business day. The Ministry publishes the specific MCEDT submission dates each year.
Claims received after that date can still be submitted and may still be processed, but the Ministry does not assure that they will be included in the following month's payment cycle.
This is an important distinction: the 18th is not a deadline after which you cannot submit a claim. It relates to which monthly processing cycle the claim can be assured of entering.
The Ministry indicates that physician payment should be received on or before the 15th of the month.
For a new physician, this means there can be a significant gap between providing a service, submitting the claim and receiving payment. Understanding that timing is important when planning the cash flow of a new practice.
8. A submitted claim is not necessarily an accepted claim
After submitting claims, you need to review the information returned by the Ministry.
One of the first places problems may appear is the Claims Error Report.
Claims may be returned because required information is missing or invalid. For example, an incorrect health card version code can result in a claim being returned for correction. The Ministry's own stale-date guidance uses an incorrect version code as an example of a claim returned to the Error Report.
Claims appearing on the Error Report are returned during the processing month and should be corrected and resubmitted promptly. If corrected information is received early enough in the same processing cycle, the claim may still be processed for that cycle.
This is why simply pressing “submit” and assuming the billing is finished can create problems. Someone needs to review the returned reports and deal with rejected claims.
9. Your Remittance Advice tells you what was actually processed
The Remittance Advice (RA) is an important part of the monthly billing cycle.
It provides information about claims that have gone through processing and allows you to see the outcome of those claims. A claim may have been paid as submitted, adjusted, or not paid as expected.
The RA therefore needs to be reconciled against what you originally submitted.
This is a different stage from a claim being returned on a Claims Error Report.
If a claim has been processed and you disagree with the Ministry's payment decision, the Ministry provides a Remittance Advice Inquiry (RAI) process. The Ministry's published guidance indicates that inquiries concerning payment decisions, overpayments or corrections can be submitted electronically through eSubmit or using the RAI process. These inquiries should generally be submitted within seven months of the date of the RA, although the Ministry states that they may still be considered after that period.
In other words:
Claims Error Report → investigate the error, correct the claim and resubmit where appropriate.
Remittance Advice → reconcile the payment result and use the Ministry's inquiry process where follow-up on an adjudicated claim is required.
Understanding that distinction early can make managing OHIP billing much less confusing.
10. Build a billing routine from day one
One of the best things a new physician can do is establish a consistent billing routine before billing begins to accumulate.
A simple workflow might look like this:
Capture the billing information → verify required patient and claim information → enter the claim → review it → submit regularly → review Claims Error Reports → correct errors promptly → review the monthly RA → reconcile payments → follow up where required.
The exact workflow will differ depending on your specialty and practice environment, but every billing process should answer the same basic questions:
Have all of my services been billed?
Were the claims successfully submitted?
Were any claims returned with errors?
What did OHIP actually pay?
Were any claims reduced, adjusted or unpaid?
Is any follow-up required?
The goal isn't simply to submit billing. It is to make sure that the billing process is completed from the date of service through to payment and reconciliation.
Getting started
Starting practice comes with enough new responsibilities without allowing billing to become an afterthought.
Before seeing your first patients, make sure your OHIP registration and MCEDT access are in place, decide how your billing will be managed, and establish a routine for submitting and reviewing claims.
You do not need to learn every OHIP billing rule before your first day of practice. You do need a reliable process for capturing your billings, submitting them on time, identifying problems and making sure the services you provided were ultimately processed correctly.
A good billing workflow should make it easier to focus on your practice—not create another administrative burden.
Official OHIP resources
For current Ministry requirements and detailed Ontario physician billing information, the following resources are useful starting points:
Resources for Physicians — Ministry information covering physician registration, claims submission, the Schedule of Benefits, billing guidance, electronic services and Health Card Validation.
Schedule of Benefits for Physician Services — the current OHIP fee schedule and payment requirements for insured physician services.
MCEDT information — information about MCEDT registration, electronic claim submission, Ministry reports, designees and current claim-submission dates.
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This article provides general information about Ontario physician billing and is not a substitute for the Health Insurance Act, its regulations, the OHIP Schedule of Benefits or current Ministry of Health billing guidance. Ministry requirements and billing rules may change.
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