What physicians need to know about the claims review process

Most fee-for-service claims submitted to Manitoba Health are adjudicated routinely and paid promptly through the regular twice-monthly payment cycle. 

Sometimes, however, Manitoba Health may hold a claim for further review before deciding whether and how much to pay. This does not necessarily mean there is a problem with the claim. Manitoba Health may simply need additional information to determine whether the service meets the requirements for payment. 

Why is my claim being reviewed? 

A claim may require further review because of the tariff billed, a Rule of Application, the information submitted with the claim, or other reasons that Manitoba Health wants to examine more closely. 

Generally, held claims are flagged as pending, and you may be asked for more information. 

What happens during a claims review?

Manitoba Health may request clinical records or other supporting information before determining whether a claim is payable. 

Some claims require manual assessment and may appear on your Remittance Advice with Explanation of Benefit (EOB) Code 77 – Pending Benefit Catalogue Item. No action is required. The claim will be processed on a future remittance once the assessment is complete. 

If you receive a request for more information, often called a review letter, do not ignore it! Review the letter carefully and consider the appropriate follow up: 

1. Review the applicable tariff in the Physicians Manual. Confirm what is required for the service you billed. 
2. Review your documentation. Your record should demonstrate the service provided and support the requirements of the tariff. Consider it through the eyes of a claim reviewer – is it clear in your notes that you delivered a service that meets the requirements of the tariff? 
3. Respond by the deadline. Provide the requested information and, if necessary, explain why you believe the original claim is appropriate. 
4. Contact Doctors Manitoba. If the hold feels out of the ordinary, or you have a large volume of claims being held, contact us. Our Practice Advice team can help you understand the request and how to respond. 

Following its review, Manitoba Health may pay the claim as submitted, assess it under another tariff, determine that it is not payable, or identify concerns requiring further review. Again, we are here to help if the outcome feels unfair. 

What if I agree wrong tariff was claimed? 

Manitoba Health’s assessment may determine that a service billed under a given tariff was eligible for payment under an alternate tariff. In these circumstances, the physician should review the assessment and tariff requirements. And, where necessary, make changes to their billing practices. 

What happens after the review?

Manitoba Health will communicate the outcome of the review. Where claims are adjusted, the physician may receive a summary of the final assessment and the resulting adjudication. 

A paid claim can still be audited

Payment does not mean a claim can never be reviewed again. 

The provincial government may subsequently audit paid claims and supporting documentation. An audit is different from holding a claim before payment: it can involve a broader retrospective examination of claims and billing practices and, where Manitoba Health determines that claims were not payable as submitted, may result in recovery of previous payments. 

Learn more about physician remuneration audits, including how Doctors Manitoba can support you. 

The best protection is the same

Whether you want to reduce the risk of a claim being held before payment or a paid claim being adjusted following an audit, the fundamentals are the same: 

• Claim the right tariff. Make sure it accurately reflects the service you provided and that you meet its requirements. 

• Document appropriately. Your clinical record should contain enough information to demonstrate the service provided and support the tariff claimed. 

• Know the rules. Be familiar with the tariffs and Rules of Application you commonly use. 

• Review your Remittance Advice. Pay attention to EOB codes and reconcile your claims promptly. 

A useful test is whether another person reviewing the chart could understand what service you provided and why the tariff you billed was appropriate.

Need help?

Doctors Manitoba’s Practice Advice team can help you understand tariff requirements, documentation expectations, claims held for review and audits. 

If you receive a claims review letter or audit notice, contact us as early as possible at practiceadvice@​doctorsmanitoba.​ca.

Further Reading

The Claims Submission and Payment Procedures section of the Manitoba Physician’s Manual explains how claims are submitted, adjudicated and paid, including pending claims and the dispute process.