How to reconcile your OHIP medical claims
OHIP payment process
The MoH (Ministry of Health) accepts claims for processing up to the 18th of the month and successful claim payments are paid on the 10th business day of the following month. All claims should be submitted to the MoH on a weekly basis so that the maximum amount of claims is processed by the cut-off date.
What is reconciliation
Reconciliation is a monthly process to determine which claims were paid in full and/or adjusted payments and which claims were not paid. Reconciliation helps to understand why the MoH made the adjustments and which unpaid claims can be corrected and resubmitted to the MoH.
Reconciliation - Payment Reports
1. On the dashboard under REPORTS & FORMS ->select "Basic Reports" -> select “Claim Summary Payment (Current Month)”
2. This report will show all information about the user's current month paid/unpaid claims. There is an option to export as an Excel file to save it for personal records. From the download drop-down menu (see screenshot) -> select “Excel Worksheet”.
3. The report will contain data in columns such as Accounting ID, patient information, claim details, amount submitted, amount paid, status and explanation codes.
4. Review both columns “$ Submitted” to “$ Paid”. If under column “Status” claim has “Adjusted Payment” status please see the next column “Explanation Code” which is the MoH description for the adjusted payment.
5. Scroll to the very bottom of your report to see all MoH explanation codes descriptions.
6. At the bottom of your report you also will find summary totals of your claims:
a) Accounting transactions – Will show an amount if there are few claims that were not processed. MoH has forwarded you $XXXX as your claims have been submitted on time (before the 18th). This amount will be reduced next month when the unprocessed claims are paid.
b) Totals of patients and services.
c) Grand Total is the amount that will be paid to the user.
For more billing tips, please check out our OHIP Billing Tip Library.
Questions? Check under the HELP tab or send an email to firstname.lastname@example.org.