There are two kinds of out of country (OOC) health services :
The OOC Prior Approval Program receives and reviews prior approval applications for funding of OOC health services from practising Ontario physicians on behalf of their patients who may require health services outside Canada.
You must complete an “Out of Province/Country Claims Submission Form”, include all original receipts and send to your local OHIP office.
Learn more about OHIP coverage for travelers.
Your Ontario physician, in consultation with you, will determine if you require health services outside Canada and will complete and submit a “Prior Approval Application for Full Payment of Insured Out of Country (OOC) Health Services” to the Ministry of Health and Long-Term Care on your behalf. An application for funding must be submitted to the ministry prior to any medical services (treatment) being rendered.
Completed applications can be sent to the ministry by fax : (613) 536-3181
There are many OOC health services that are requested and approved by the MOHLTC. Examples of some of the services approved for OOC funding include bariatric surgery, cancer treatment, psychiatric inpatient treatment, DNA testing and CT scans.
To qualify for ministry funded OOC health services, the service(s) must be :
Treatment considered experimental in Ontario, treatment for research or for a survey does not qualify for funding.
The amount of time required to process an application for OOC prior approval varies. Completed urgent applications will be reviewed immediately and can be processed in as little as 24 hours. However, more complex applications can take 6-8 weeks to process. Incomplete applications and those without sufficient supporting medical documentation such as clinical letters from treating Ontario physician(s) may take longer to be processed.
When the ministry has reached a decision regarding your application, a decision letter will be sent to your Ontario referring physician by fax. A copy of the letter will be sent to you (the patient or the patient’s family) by courier. The ministry’s decision letter will clearly describe the service(s) for which OOC funding has been approved or denied.
Yes. The ministry has a toll-free telephone number (1-888-359-8807) to assist patients and physicians if they have questions about the process or the status of an application. An e-mail address has also been established for this purpose : OOCPRIORAPPROVALINQ@moh.gov.on.ca.
No, ministry funding is only provided for approved OOC health services. The service(s) approved are described in the ministry’s decision letter. OHIP does not pay for ambulance services, transportation costs, or out-of-hospital food/ accommodation/drugs or take-home prescriptions.
According to O.Reg 552, s. 28.4(5)1, an application for prior approval “….. must be submitted to the General Manager by a physician who practices medicine in Ontario on behalf of an insured person……” The ministry does not have the ability to request or rely on the opinion of a physician who does not practise medicine in Ontario. This regulation also stipulates that the service or treatment must be generally accepted in Ontario as appropriate for a person in the same medical circumstances.
Yes. You may submit additional information in support of your application, to the ministry for further consideration of your application. All information will be carefully reviewed by the ministry and you will be advised of the outcome of the review in writing. There is no limit to the number of times you can request further consideration of your application if you have additional information which may not have been provided to the ministry previously. The ministry will continue to review all information that is provided in support of an application.
If the ministry’s decision remains unchanged, you can request a hearing before the Health Services Appeal and Review Board (HSARB).
The HSARB is an independent body made up of members of the general public and is not part of the ministry. This process ensures that all reviews are conducted in a way that is fair and equitable for everyone.
The Board is responsible for conducting reviews (or hearings) related to a number of ministry programs including requests for OOC prior approval of funding for health services. To request a hearing before the Board, you must advise the HSARB in writing of your intention to appeal within 15 days of receiving your letter of denial or the letter responding to the review. The Board’s address is provided in the ministry’s denial letter.
When your request for an appeal is received by the Board, the Board will acknowledge receipt of your request and will provide you with a due date for submission of relevant documentation. You will also be provided with the Board’s procedural guidelines to assist you throughout the process. Hearings are held in Toronto and you will be given the choice of attending the hearing in person or having a written or telephone hearing. You do not have to attend the hearing in person if you choose to have a written or telephone hearing.
Before your hearing is held, you may be contacted by the Board to participate in a “pre-hearing conference” to provide clarification regarding your case or to determine if the date of your hearing should be moved ahead. Pre-hearing conferences are always conducted by telephone and in some cases, can result in a settlement of your appeal.
To learn more about the HSARB process, visit the HSARB website or call their toll-free number 1-866-282-2179.
It is not required; however, it‘s a personal decision that can only be made by you or your family. Ministry information indicates that only 10-25% of hearings before the Board involve legal representation.
You are given the opportunity to request a hearing and if you would like more information on the process, the toll-free number for the HSARB is 1-866-282-2179. This is a personal decision that can only be made by you or your family.
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