The Ministry of Health and Long-Term Care (the ministry) receives and processes requests for funding for planned medical services out of Ontario, but within Canada. In order to receive full funding, certain insured services must receive prior written approval before any services are provided. Therefore, the ministry recommends that prior written approval be received from the ministry before the requested out-of-province (OOP) (but within Canada) insured medical services are provided. Requests are to be directed to the attention of Provider Payment Programs in the Health Services Branch (HSB).
Physicians seeking elective, hospital or medical treatment OOP on behalf of their patients complete and submit a prior approval application requesting funding before services are provided.
The ministry requires the referring Ontario physician or the OOP physician who will be providing the services to complete an application on behalf of the Ontario resident. The request is submitted for approval to the Ministry of Health and Long-Term Care. The application should be complete and legible, clearly describing the patient's medical condition, recommended treatment, availability of services in Ontario and signed by both the patient and the physician providing the services.
The request should state the following:
Currently there is no specific OOP form; however, the Prior Approval Application for Full Payment of Insured Out-of-Country Health Services Form (Form 4520-84) is acceptable. The form can be downloaded at: www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/GetFileAttach/014-4520-84~1/$File/4520-84E.pdf
To qualify for ministry funded OOP health services, the ministry requires the following criteria to be met:
Completed application forms may be mailed or faxed to the ministry at the address below:
The regulations under the Health Insurance Act (HIA) provide for coverage of insured services rendered in a hospital outside Ontario but within Canada if:
Once a completed application form is submitted to the ministry, the documentation is assessed. If it is determined that the circumstances meet the required criteria, a decision letter will be sent to the referring Ontario physician or the OOP physician by fax and a copy of the letter will be mailed to the patient. The ministry's letter will clearly describe the service(s) for which OOP funding has been approved or denied and will clearly outline the following if applicable:
The amount of time required to process an application for OOP Prior Approval Application varies. Completed urgent applications will be reviewed immediately and will be treated on a priority basis. Non-urgent or incomplete applications may take up to 2-3 weeks.
The decision letter sent by the ministry is based on the medical documentation provided with the application. If the patient's circumstances change, a new prior approval application may be submitted to the ministry requesting different treatment and/or services as well as the proposed OOP physician/facility for consideration.
The ministry has a toll-free number (1-888-359-8807) to assist patients and physicians if they have any questions about the process or status of an application.
In the case of requests for prior approved services, the ministry only covers costs for prior approved insured hospital and physician services. OHIP does not pay for ambulance services, travel, accommodation, meals (except where included as part of insured services), or take-home prescriptions. Treatment that is generally accepted in Ontario as experimental, for research or a survey including clinical and drugs trials is also excluded as an insured service.
If you require OOP (but within Canada) hospital or medical services as the result of a work-related accident, the prior approval process is not applicable and an application form should not be submitted to the ministry. Please contact the Workplace Safety and Insurance Board (WSIB) to discuss coverage as OHIP does not insure services to which a person is entitled under the Workplace Safety and Insurance Act (WSIA).
There are 2 options:
If you are requesting an internal review, the ministry requires that additional information and/or medical documentation be provided. This information can be sent to the ministry by mail (to the address provided below) or by fax: 1-866-221-3536 or 613-536-3181.
On completion of the internal review, the ministry will prepare a decision letter which will be sent to the referring physician by fax and a copy will be sent to the patient by courier.
The ministry will continue to re-examine applications as long as additional relevant information is provided for review.
If an application for OOP prior approval has been denied by the ministry, either initially or following an internal review and you have no additional relevant information to provide, you may request an appeal of the ministry's decision to the HSARB.
The HSARB is independent of the ministry. To request a hearing before the HSARB, the patient or his/her physician must advise the HSARB in writing of their intention to appeal within 15 days of receiving the denial letter.
The Board Address is:
For information about the HSARB, pre-hearing telephone conferences, appeals and procedures, please contact the HSARB at:
Call ServiceOntario, Infoline at:
1-866-532-3161 (Toll-free in Ontario only)
In Toronto, TTY 416-327-4282
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