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OHIP Claim Process

Question:  What are the steps, from beginning to end, for submitting claims to OHIP, and resubmitting rejected claims?

Answer: There is a process to follow that will ensure that all claims are submitted and/or resubmitted in a timely manner so you maximize your claim remittance.  Below are the basic steps and a brief description of each step.

  1. Enter the OHIP claim as a new invoice in WINK
  2. "Batch" your claims and send them to OHIP.  Print a report of the sent claims (if you wish).
  3. Watch for Documents to come back from OHIP (Batch Edit, Claim Error and Remittance Advice reports)
  4. Resubmit rejected/error claims

 

Step 1 - Enter the OHIP claim as a new invoice in WINK

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  • Go into the patient's profile and click on "New Invoice"
  • Enter the following information in the following order:
    • Doctor (who performed the service and is to be paid)
    • Primary Insurer must be set to "OHIP [WINKsync]"
    • Only when necessary, enter a "Referred By" doctor
    • Enter the "Exam Date" for the date the service was provided
    • Enter the "Product Name / Sku" .  This MUST be a valid, WINKsync, OHIP service code selected from the list of "Eye Exams and Other Services". (ie. V404A , V410A, etc.).  Only OHIP service codes should appear on this invoice.  Any service paid by the patient (ie. Retinal Photos, OCT, etc.) must be invoiced on a separate invoice.
    • Enter the ICD diagnostic code.  Use the binoculars to access the list of acceptable ICD codes.

As you enter these OHIP claim invoices throughout the day/week, they will accumulate until you are ready to send them to OHIP (generally once a week for an individual doctor or daily for a multi-doctor practice).

 

Step 2 - "Batch" your claims and send them to OHIP

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  • From the Main Menu, select Company >> Batch Actions >> Insurance Claims
  • Select the Dr.'s account for whom you are sending the claims, in the "Account Name" field.
    • If the Dr. is a member of a "Group" submitting to OHIP, the Group Account # will be selected in the "Account Name" field.  The individual Dr. from within that Group should be selected in the "Practitioner" field
    • Do NOT enter the Dr.'s name in the "Practitioner" field if he/she is not a member of a submitting Group.  This field is only used for Doctors who are in a registered Group with OHIP.
  • Leave the "Status" as "Unsent" to batch all claims waiting to go to OHIP.
    • You can also use the "Sent" status to recreate a previously sent batch
    • You can use the "All" status to create a list of sent and unsent claims within a specified date range.
    • We recommend that you leave the date ranges blank to eliminate the possibility of missing any claims.  These date ranges should be used only to create very specific lists, but not for sending claims on a regular basis. 
    • The "Invoice Number" field can be used to create a batch of specific claims that you want to send in a separate batch.  For example, you get special permission from OHIP to resubmit certain out-dated claims for payment, you might use this field to create a specific batch of just those claims.
  • Click on "Find" to create the batch of claims waiting to be sent to OHIP.
    • Scrutinize the list making sure that all claims have health card #'s, proper exam dates, proper service codes, proper diagnostic codes and a claim amount greater than $0.00
    • To fix a claim:
      • click on the claim to highlight it in blue
      • then right-click on the blue area and select "Open Claim". 
      • Make your changes and don't forget to Save
      • Close the claim invoice and you will be returned to the Batch Insurance Claims window.  Changes will not be reflected until you recreate the batch.
  • Once you are satisfied that your batch of claims is perfect ... click on "Send Batch".  WINK will tell you when the batch has been successfully sent.
  • Print a report of the claims just sent, if you wish.  
    • Reports >> Insurance >> Claim Status
    • Change the "Date" field to "Claim Sent Date" and be sure the date matches the date you sent the claims.
    • Select the Store, if necessary
    • Select "OHIP [WINKsync]" as the Insurer
    • Select the Doctor
    • Choose either "Unpaid Only" or "Show All" in the "Balance Due" field.  If this is being printed right after you sent the claims, they will all be unpaid anyway, so it doesn't matter which you pick.
    • Click on "Generate"

 

Step 3 - Watch for Documents coming back from OHIP

Once a day, WINK will "sniff" your Go Secure account to see if there are any new documents in your "mailbox" and will download those documents into your WINK program.  WINK also automatically "processes" those documents to indicate if a claim has an error, has been rejected, or has been paid. When a batch of claims is sent to OHIP, three things happen to that batch on OHIP's end.

  1. They send an acknowledgement back to the sender that the batch was received.  This is call a "Batch Edit" report.  It is generally sent within 24 hours of receiving your batch.  Some offices will print this document and attach it to the printed list of claims submitted so they know that the batch was received by OHIP.
  2. The batch of claims then goes through a "pre-edit" program that will pick up obvious errors, like an incorrect Version code on a health card #, or an incorrect service code for the patient's age, etc.  This preliminary peek at the claims creates a "Claims Error" report that is also sent back to the sender ... usually within 24 - 48 hours after the batch was received by OHIP.  These claims should be fixed and resubmitted for payment, which we will talk about in Step 4.
  3. The claims that pass the pre-edit program continue deeper into OHIP processing system.  Here is where the claims are scrutinized more carefully and are either paid or rejected due to other reasons, for example, a duplicate claim.  These payments and rejections are reported to you in a "Remittance Advice" file which is generally sent out in the first week of each month.

Your job is to check for the documents to ensure that claim errors/rejections are resubmitted in a timely manner.

Check out this Video
  • From the Main Menu, select Reports >> Insurance >>Documents
  • The Documents are arranged in descending order based on the date WINK downloaded them from your Go Secure account.  This means the most recent documents will always be at the top of the list.
  • When you have a Claim Error or a Rejected claim on your Remittance Advice file, proceed to Step 4.
  • NOTE: Do not cancel a claim before the Claim Error or Rejection is received from OHIP.  Let WINK mark the claim as an Error or a Rejected claim before you cancel a claim and/or resubmit a claim.  Pre-empting claim resubmission will cause reconciliation errors on the original claim.

 

Step 4 - Resubmit rejected/error claims

When WINK processes the Claims Error report, it finds the invoice and displays the error code above the invoice, next to the OHIP [WINKsync] insurer.  When WINK finds a rejected claim in the Remittance Advice file, it finds the invoice and displays the error code in the Description field of the service code.  Either way, you will generally want to resubmit the claim (unless it's a duplicate).

  • Bring up the claim/invoice in the patient's profile.
    • TIP: Just type the invoice # in the Search field on the Main Menu ("i123") and the claim will magically appear!
  • Edit >> Credit >> Cancel the claim.  We suggest using the error code in the reason for cancelling the claim/invoice ("EH2 error").
  • SAVE
  • Create a "New Invoice"/claim being sure to specify the Exam Date with the original service date.

As you might have noticed, we are now back to "Step 1 - Enter the OHIP Claim as a new invoice in WINK".  And so, the cycle starts all over.

Note that ALL claim errors/rejections should be cancelled ("edit>>credit>>cancel"), even if you are not resubmitting the claim.  This will prevent them from looking like outstanding claims on reports.

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