How to start billing OHIP

The hard part of OHIP billing is not the codes. It is that nothing tells you the sequence, every step is gated on the one before it, and the two longest waits are at the very start where you cannot do anything about them.

This guide is the whole arc. Each step links out to a deeper guide where there is one.

Step 1: Get a billing number

The OHIP billing number is issued by the Ministry of Health to physicians licensed by the CPSO. It identifies you on every claim and everything downstream depends on it.

Two things catch new physicians out:

• It is not automatic. Nobody applies for you, including your hospital.
• It takes time. Start the application before you need it, not when you start seeing patients.

If you will be working within a hospital department or a group practice, you will also need to be registered as a member of that group's ministry group number. That is arranged by the group's administrator and is separate from your own registration.

Step 2: Register for MCEDT

MCEDT — Medical Claims Electronic Data Transfer — is the channel every electronic OHIP claim travels through. Registration means a GO Secure account, EDT enrolment using the two identifiers on your ministry registration letter, and then designating whoever will submit for you.

The physician has to do this personally. A billing company can be designated once you are enrolled, but it cannot enrol on your behalf.

Full walkthrough: how to register for MCEDT.

Step 3: Set up how you will submit

Your MCEDT designation is the channel. What travels down it still has to be built, validated, sent, retrieved and reconciled, and that is what a billing service does for you:

• builds the claim and checks it before it goes, so the avoidable rejections never happen;
• submits it through your designation on a continuous basis rather than in a month-end push;
• retrieves the error reports and remittance advices as they arrive, and turns a rejection into something on your list with the reason attached;
• reconciles what OHIP paid against what you submitted, which is the only way to find claims that never settled at all.

IntelAGENT is priced as a percentage of what you are actually paid: self-service is 0.25% of paid claims, capped at $39.99 a month, and the first three months are free. Where you would rather have a person doing the billing — because fee-code selection needs judgement, or because you want the work entirely off your desk — there is a tier with a dedicated billing agent instead. See billing software vs a billing agent and pricing.

Step 4: What a claim actually contains

However it is submitted, every OHIP claim carries the same core facts:

• The patient — health number, version code, date of birth and sex, matching the ministry's record exactly. See health card validation.
• The service — one or more fee schedule codes, with a quantity, and the date each was rendered.
• A diagnostic code — the ministry's own three-digit list, not ICD-10, and not zero-padded.
• The setting — a service location indicator, and for hospital services a facility number and sometimes an admission date.
• The referring physician, where the service requires one. Six digits, including any leading zero.
• The group number, if you are billing under one.

Getting any of these wrong produces a rejection rather than a reduction, which is the better of the two outcomes because you find out in days instead of weeks.

Step 5: The monthly cycle

OHIP does not pay continuously. Three dates define the rhythm:

A claim submitted on the 19th of January is therefore paid in mid-March. That gap, not a lost claim, is the usual explanation when a new physician thinks something has gone wrong.

Step 6: The work that recurs

Once you are running, OHIP billing settles into two recurring jobs.

Weekly: clear your rejections. Every submitted batch has an error report, and a rejected claim sits at zero until somebody fixes and resends it. See common OHIP claim rejections.

Monthly: reconcile the Remittance Advice against what you submitted. This is the only way to find claims that were neither paid nor rejected — the ones that were never actually sent. See how to read an OHIP Remittance Advice.

The five mistakes new billers make

• Waiting to apply for the billing number. The ministry's timeline is not yours.
• Deferring the billing to the weekend. Encounters billed days later lose the premiums, and some lose the encounter entirely.
• Never downloading the error reports. A rejection you have not read is indistinguishable from a claim that was never made.
• Assuming the deposit is the answer. The deposit is net of reversals. It tells you what arrived, not what was paid for.
• Leaving group billing to the group. Group totals can be right while your individual share is wrong, and nothing flags it.

Frequently asked questions

Sources

• OHIP Schedule of Benefits and fees — Government of Ontario.
• Physician payment — Ontario Ministry of Health.
• Medical Claims Electronic Data Transfer (MCEDT) — Ontario Ministry of Health.

Related reading