Stale-dated OHIP claims and RAIs: the 3-month rule, VJ7 and how to recover them
OHIP gives you three months to submit a claim and 7 months to question a processed one with a Remittance Advice Inquiry (RAI). Here are both deadlines, the steps for each, and how to pick the right route.
The time limits at a glance
- 3 months to submit a claim
- 7 months to send an RAI
- 18th usual monthly receipt date
| Limit | What it covers | Clock starts on | Earlier limit |
|---|---|---|---|
| 3 months | Submitting a claim, services on or after April 1, 2023 | Service date | Six months |
| 3 months | Resubmitting a rejected claim as a regular claim (after that, use the stale-dated process) | Service date | — |
| 7 months | Sending an RAI, services on or after April 1, 2023 | Date of the RA showing the claim | 4 months |
| 7 months, may be considered later | RAI about an overpayment or a wrong health number or service date | RA date | — |
Claims received by the 18th of the month are usually processed the following month, so leave yourself time. Our OHIP billing submission cut-off dates schedule lists the monthly dates.
The three-month rule
A claim submitted after the window is stale-dated and rejects to your Error Report with VJ7. The Ministry pays it only if one of two exceptions applies.
| Exception | Route |
|---|---|
| 1. First submitted within three months and rejected to an Error Report | Correct it and resubmit it after the window has closed, through the stale-dated process |
| 2. Extenuating circumstances prevented you from submitting it on time | Letter to [email protected], reviewed case by case |
The rule in detail
For services provided in Ontario on or after April 1, 2023, a claim must reach the Ministry within three months of the service date. Before that date, the limit was six months (INFOBulletin 231001).
A claim submitted after the three-month window is a stale-dated claim. It is rejected to your Error Report with code VJ7. The Ministry does not pay stale-dated claims unless one of the two exceptions above applies.
Resubmitting a claim that was first sent on time
- Correct every error on the claims.
- Upload all the corrected claims together in one stale-dated claim file through MCEDT. On the GO Secure website, choose file upload, then the stale-dated claim file option. Your billing software may have the same option.
- Email [email protected] with the details in the table below.
- Send a separate email for each physician or group. Don't combine requests.
| The email must include | Details |
|---|---|
| Who you are | Your full name, address and phone number |
| Billing identity | Your six-digit billing number and/or four-digit group number |
| Claim list | Health number, service date and fee codes for each claim |
| The file | File number and upload date of the stale-dated file |
| Proof of timing | The Error Reports showing each claim was first submitted within three months |
Why not resubmit it as a regular claim?
If a claim was submitted within three months and rejected to an Error Report, it can still be paid once it is corrected. The Ministry encourages you to resubmit as soon as possible after the rejection.
Once the three months have passed, a corrected claim sent as a regular claim will reject with VJ7. Use the stale-dated process instead.
Claims that were never sent on time
These are paid only for extenuating circumstances: extraordinary and unusual events that arise suddenly and unexpectedly, and are beyond your control (Billing Brief).
| Situation | Qualifies? |
|---|---|
| Administrative or operational errors in the office | No |
| A misplaced folder and a claim a billing clerk missed | No (Billing Brief example) |
| A sudden, unexpected event beyond your control | Reviewed case by case |
To ask for an exception, send a signed letter:
- Write a letter, on letterhead (INFOBulletin 231001).
- Include your name, address and phone number, and your billing and/or group number.
- List the claims: health number, fee codes and service dates.
- Give the reasons the claims could not be sent on time.
- Have the physician or a group representative sign it. Signatures from billing agents or office staff are not accepted.
- Send it to [email protected], one letter for each physician or group.
The Ministry reviews each request case by case. If it accepts, it sends a decision letter with instructions for submitting the claims.
What an RAI is
A Remittance Advice Inquiry questions a claim that was already processed and appears on your Remittance Advice (RA). Use it when:
- OHIP paid too little
- OHIP paid too much
- OHIP changed a claim and you want the Ministry to look again
- You want an explanation of a payment
| Where the claim is | What it means | What to do |
|---|---|---|
| Error Report | Never processed for payment | Correct it and resubmit it |
| RA | Processed | Send an RAI. Don't send the claim again |
Why resending a processed claim doesn't work
An RAI is not a way to fix a rejected claim. A claim on your Error Report was never processed for payment, so you correct and resubmit it.
A claim on your RA was processed, so you don't send it again. A second copy will usually reject, for example as a duplicate (RA code 35), and the issue stays open.
The RAI time limit
Send an RAI within 7 months of the RA date on which the claim appears, for services on or after April 1, 2023. The clock starts on the RA date, not the service date (INFOBulletin 230402).
Earlier limit and the one exception
INFOBulletin 230402 extended the limit from 4 months to 7.
The Ministry's Resource Manual notes one exception. Inquiries about overpayments, or about claims submitted with a wrong detail such as the health number or service date, should also be sent within 7 months, but they may still be considered after that (Resource Manual).
How to submit an RAI
| eSubmit | Paper form | |
|---|---|---|
| What it is | The Ministry's secure channel for RAIs and supporting documents | Remittance Advice Inquiry form (0918-84) |
| How to send | GO Secure (OPS BPS Secure) website → eSubmit → Remittance Advice Inquiry | Mail it, or fax it to 1-905-434-4186 |
| Attachments | Up to 15 per submission | Attach supporting documents |
| Access | MCEDT access; staff acting for you need their own eSubmit permissions | — |
- Pick a channel: eSubmit or the paper form.
- Identify the claim: billing and group number, health number, service date, fee code and the RA it appears on.
- Explain what you think is wrong.
- Attach anything that supports it, such as clinical notes, start and stop times or an operative report.
- Watch your MCEDT download page for the response, next to your RAs and Error Reports.
eSubmit through billing software
Billing software can also upload an RAI through MCEDT as an eSubmit upload file, which follows a set file-naming format. You need MCEDT access, and staff acting for you need their own eSubmit permissions.
After the Ministry responds
The Ministry may adjust the payment, confirm it was paid correctly, or ask for more information.
If the Ministry says its decision is final and you still disagree, there is a formal appeal with a short deadline. Check the current steps with the Ministry before you rely on a date.
Which route does a claim need?
| Situation | What to do |
|---|---|
| Rejected to the Error Report, still within 3 months of the service date | Correct it and resubmit it as a regular claim. |
| Rejected to the Error Report within 3 months, now past 3 months | Correct it, upload it in a stale-dated claim file through MCEDT, then email [email protected] with the Error Reports. |
| First sent more than 3 months after the service (VJ7) | Payable only for extenuating circumstances, by letter to [email protected]. Office errors don't qualify. |
| On the RA, paid less than expected or $0, and you disagree | Send an RAI within 7 months of the RA date. Don't resubmit. |
| On the RA, but overpaid or sent with a wrong health number or service date | Send an RAI. Aim for 7 months; the Ministry may consider it later. |
Practical tips
- Check your Error Reports as soon as they arrive, not just your RA. A rejected claim never shows on the RA, so it is easy to miss until the three months have passed.
- Track the three-month date for every rejected claim. Fixing it inside the window is a normal resubmission. After, it needs the stale-dated file and an email.
- Keep every Error Report until its claims are paid, and every RA for at least the 7-month RAI window.
- Look for a matching 55 or 57 line on the same or a later RA before you send an RAI. The Ministry may already have adjusted the claim.
- Questions about stale-dated claims: the Ministry's Service Support Contact Centre, 1-800-262-6524.
How APEX helps
Sources
INFOBulletin 231001: Update, three-month submission timeframe for in-province claims
INFOBulletin 230402: Update, claim submission timeframe for in-province accounts
Billing Brief: Rules regarding claim submission periods and stale-dated claims
Resource Manual for Physicians: Claims submission (Ministry of Health)
eSubmit: ready, set, GO Secure (Ministry of Health)
Remittance Advice Inquiry form 0918-84 (Central Forms Repository)
APEX offers every physician or group a unique, transparent overview over their billing records.