Ontario Health Insurance Plan

OHIP Out of Province Services - Prior Approval

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).

How to Apply for Out of Province Prior Approval

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:

  • Patient's name, address, health number, date of birth; and
  • Referring physician's name and address of the facility where the services will take place; and
  • Details on the requested procedure and patient's symptomatology; and
  • If the facility is publicly funded or private.

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:

  • Must be an OHIP eligible resident of Ontario; and,
  • The services must be performed at a publicly funded hospital or facility which participates in a reciprocal hospital billing agreement or in a facility that the ministry has entered into a Preferred Provider Arrangement; and,
  • The requested service(s) must be insured service(s) in Ontario; and must not be "experimental", part of a trial or survey.
  • The service, if provided in Ontario is one to which the insured person would be entitled to without charge.

Completed application forms may be mailed or faxed to the ministry at the address below:

OOP Prior Approval Request
Provider Payment Programs
Health Services Branch
1055 Princess Street
P.O. Box 168
Kingston, ON K7l 5T3
Fax: 1-866-221-3536 or 613-536-3181
Phone: 1-888-359-8807

Eligible Hospitals/Facilities

The regulations under the Health Insurance Act (HIA) provide for coverage of insured services rendered in a hospital outside Ontario but within Canada if:

  • the hospital that will provide the service is approved by the General Manager for the purpose of the plan; and,
  • the hospital that will provide the service is licensed or approved as a hospital by the provincial hospital licensing authority in whose jurisdiction the hospital is situated; and,
  • the service, if it were performed in Ontario, is one to which the insured person would be entitled without charge in a hospital in Ontario; and,
  • in the case of an in-patient service, in Ontario, the insured person would ordinarily have been admitted as an inpatient of a public hospital to receive service.

Out of Province (within Canada) Application Process

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:

  • Name of person for whom the service(s) have been approved; and
  • period of time approval is valid for; and
  • the service(s) that have been approved; and,
  • the facility where the service(s) have been approved and will be provided; and,
  • where relevant, the amount that the ministry will pay towards the cost of the service(s).

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.

Services not eligible for OOP prior approval funding

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.

Workplace Safety and Insurance Board (WSIB)

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).

What to do if your prior approval application for full payment of insured out-of-province health services was denied?

There are 2 options:

  1. Request an internal review of your application; and/or
  2. Request a hearing before the Health Services Appeal and Review Board (HSARB).

1) Internal Review Process (IRP)

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.

Ministry of Health and Long Term Care
Health Services Branch
1055 Princess Street
P.O. Box 168
Kingston, ON K7L 5T3

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.

2) Health Services Appeal and Review Board (HSARB)

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:

Health Services Appeal and Review Board,
151 Bloor Street West, 9th Floor,
Toronto - ON. M5S 2T5.

For information about the HSARB, pre-hearing telephone conferences, appeals and procedures, please contact the HSARB at:

Telephone: 416 327-8512 or 1-866-282-2179
Facsimile: 416 327-8524
Email: hsarb@moh.gov.on.ca
Website: www.hsarb.on.ca

For More Information

Call ServiceOntario, Infoline at:
1-866-532-3161 (Toll-free in Ontario only)
TTY 1-800-387-5559.
In Toronto, TTY 416-327-4282
Hours of operation : 8:30am - 5:00pm

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