What outcomes can I expect to my claims?

What outcomes can I expect to my claims?

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There are a handful of outcomes. To explain have a look at the diagram and description below:

The Four Scenarios

Most OHIP claims follow the ideal flow of billing as shown in the right most flow chart (Best Scenario).

A Claim is entered and saved to the UNSUBMITTED status, and then it is 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).

A Rejected Claim is fixed by the user and saved to the UNSUBMITTED status, and then it 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 can be claims paid previously, certain procedures that are limited to so many in a period, service codes that cannot be charged in combination with others etc… In this scenario it is the user, not an automated process that moves the claim from the SUBMITTED status to a status outside the Billing Cycle.
These statuses are PAID BY USER or CLOSED.


The last possible scenario is the unenviable “Feeling Lost Scenario”.
This involves claims that seem to not to have triggered a response by OHIP. They were neither rejected nor paid they seem to have been “ignored” by OHIP or “forgotten” by the user. Hype Medical has a tool for detecting such claims . It is important to search for these on a monthly basis. Most of these claims need to be moved from the status of SUBMITTED to UNSUBMITTED (use the bulk actions to move many claims in a single click, see FAQ12). UNSUBMITTED claims will then be submitted to OHIP, in a single click.
In most cases such claims return $0.00 payment by OHIP with an explanation code of 35; meaning “we already paid you”. Code 35 is an example where it is the user that moves the claim outside of the billing cycle to the status of PAID BY USER.

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