Resubmit when your claim was wrong. File a Remittance Advice Inquiry when the claim was right and the adjudication was not. An RAI needs the claim identifiers, a clear statement of expected versus paid, and documentation that supports the expectation — an operative note, a consultation letter, a time record. The answer comes back weeks later on a Remittance Advice, so you have to track the inquiry yourself.
In IntelAGENT an inquiry is filed from the claim it concerns and stays attached to it until the answer lands. See how →
Resubmit or inquire?
Getting this wrong wastes the most time of anything in the dispute process, because each path fails silently when used for the other's job.
| Situation | Route |
|---|---|
| Wrong fee code submitted | Resubmit corrected |
| Missing or invalid diagnostic code | Resubmit corrected |
| Wrong facility or group number | Resubmit corrected |
| Health card invalid or version code wrong | Resubmit corrected |
| Claim correct, paid at a lower amount than the Schedule provides | Inquiry |
| Premium refused where you believe the criteria were met | Inquiry |
| Claim already paid, then reversed or adjusted downward | Inquiry |
| Multiple services reduced as duplicates when they were distinct | Inquiry |
| Claim never appeared on any Remittance Advice | Neither — check submission first |
That last row is worth dwelling on. A claim that never appears on an RA was probably never accepted, which is a submission problem rather than an adjudication problem. Filing an inquiry about a claim the ministry never received produces nothing. Check the rejection and error reports before concluding that a claim was adjudicated at all.
What an inquiry needs
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The claim, unambiguously
Account and group as submitted, physician billing number, patient health number, service date, fee code, and the claim reference as it appeared on the Remittance Advice. An inquiry the ministry cannot match to a specific adjudicated claim cannot be answered.
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Expected versus paid, in numbers
State the amount you expected, the amount paid, and the difference. Not "this was underpaid" — the specific figures, because that is what gets compared.
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The reason you believe it is wrong
One or two sentences. If the Schedule supports your position, say which provision. Vague disagreement gets a vague answer.
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Documentation
The part people skip, and the part that decides the outcome. An operative note for a procedure, a consultation letter for a consultation, a time record for anything time-based, a discharge summary for an inpatient stay. The document should make the case on its own.
Documentation is patient information. Anything you attach to an inquiry is clinical material about an identifiable patient, and it has to travel the way clinical material is supposed to travel — through the ministry's own channel, not by ordinary email. Attachments sent the wrong way are both a privacy problem and, practically, an inquiry that never gets considered.
The cases that actually come up
Four patterns account for most inquiries worth filing:
- A premium refused on criteria you believe were met. Most often time-based — a service rendered inside a premium's hours, adjudicated as though it were not. The time record is the evidence. See special visit premiums.
- Distinct services reduced as duplicates. Two genuinely separate encounters on the same day, or a procedure plus an unrelated assessment, netted down to one. The notes have to show they were separate, which means the notes have to say so at the time rather than being reconstructed later.
- A quantity or multiplier ignored. Several units of a service paid as one. Worth checking your own submission first: if the quantity did not reach the ministry, that is a resubmission, not an inquiry.
- A claim paid then clawed back. An adjustment or reversal on a later Remittance Advice reducing something already settled. These need the original claim and the adjustment line together, and they are the hardest to notice in the first place — which is the argument for reconciling every RA rather than only checking the deposit. See reading a Remittance Advice.
Tracking what you filed
The outcome of an inquiry arrives as a line on a future Remittance Advice, not as a reply addressed to you. Nothing announces it. If you are not holding a list of open inquiries and checking each RA against it, a resolved inquiry is indistinguishable from an ignored one.
What has to be recorded per inquiry: the claim, the date filed, what you asked for, what you attached, and the outcome when it lands. Kept in a separate list, this goes stale the first busy week. It belongs next to the claims, because the useful question — which of my open inquiries have been answered — needs both sides in one place. In IntelAGENT an inquiry is filed from the claim it concerns and stays attached to it, so the answer lands against the claim when the Remittance Advice carrying it is reconciled.
One inquiry per claim. Filing a second inquiry on a claim that already has one open does not add weight; it adds ambiguity about which one is being answered. Wait for the first to resolve.
Inquiries filed from the claim, tracked to the answer
An inquiry is only worth filing if someone notices the answer. In IntelAGENT the inquiry never leaves the claim it concerns.
- Inquiries filed from the claim. The identifiers come from the claim record rather than being retyped, so the inquiry matches what was actually submitted.
- Documentation attached in place. Operative notes and supporting documents are attached to the claim and travel with the inquiry.
- Open inquiries listed. What is outstanding, how long it has been outstanding, and the claim it belongs to.
- Resolution matched back. When the outcome arrives on a Remittance Advice it is attached to the inquiry rather than appearing as an unexplained adjustment.
Three months free, then 0.25% of paid claims, capped at $39.99 a month. IntelAGENT has submitted OHIP claims since 2016 for more than 2,000 Ontario physicians.
Frequently asked questions
What is a Remittance Advice Inquiry?
It is the formal mechanism for asking the ministry to review how a claim was adjudicated — typically a claim paid at less than you expected, refused for a reason you disagree with, or adjusted after it was already paid.
When should I resubmit instead of filing an RAI?
Resubmit when the claim had something wrong with it that you can fix: a wrong fee code, a missing diagnostic code, a bad facility number. File an RAI when the claim was correct as submitted and the adjudication is what you disagree with.
What should I include with an RAI?
The claim identifiers, what you expected and what was paid, and the clinical documentation that supports it — usually an operative note, a consultation letter or a time record. An inquiry with no supporting document is an assertion, and tends to be answered as one.
How long does an RAI take?
Weeks rather than days, and the outcome arrives on a later Remittance Advice rather than as a separate letter. Nothing announces it, so the inquiry has to stay attached to the claim until it resolves. In IntelAGENT it does, and the answer lands against the claim when that Remittance Advice is reconciled.
Sources
- Ministry of Health — physician payment — adjudication and payment process.
- OHIP Schedule of Benefits and Fees — the provisions an inquiry argues from.
- MCEDT reference manual (PDF) — the electronic channel inquiries and attachments travel through.
Related reading
Reading a Remittance Advice
Where underpayments and adjustments show up.
GuideWhy claims get rejected
The cases that are resubmissions, not inquiries.
GuideSpecial visit premiums
The most commonly disputed refusals.
ProductThe IntelAGENT web portal
Inquiries filed from the claim and tracked to the answer.