Physicians seeking elective hospital or medical treatment OOP on behalf of their patients must complete and submit a prior approval application form requesting approval for funding before services are provided.

The ministry requires the referring Ontario physician or the OOP physician who will be providing the service(s) to complete an application on behalf of the Ontario resident. The application must be complete and legible, clearly describing the patient's medical condition, recommended treatment, availability of services in Ontario and be signed by the patient and either the physician providing the services or the referring physician.

The request should state the following:

• patient's name, address, health number, date of birth; and
• referring physician's name; and
• the name of the physician providing the services (if known); and
• the name and address of the facility where the services will take place; and
• details on the requested procedure and the patient's symptomatology; and
• whether the facility is publicly funded or private.

The Request for Prior Approval Application for Full Payment of Insured Out-of-Province Health Services (in another province/territory) form 4963-84 can be downloaded at: http://www.health.gov.on.ca/en/pro/forms/ohip_fm.aspx

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 in Ontario; and must not be "experimental", part of a trial, research or a survey; and
• 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 Facility Payment Unit
Health Services Branch
1055 Princess Street
P.O. Box 168
Kingston, ON K7L 5V1
Fax: 1-866-221-3536 or 613-536-3181
Phone: 1-888-359-8807

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 the service.

Once a completed application form is submitted to the ministry, the documentation is assessed. A decision letter is sent to the referring Ontario physician and/or the OOP physician by fax and a copy of the letter is sent 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 requested; and
• the service(s) that have been approved or denied; and,
• the name of the proposed facility where the service(s) are requested ; and,
• where relevant (and if approved), 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. Properly completed urgent applications will be reviewed immediately and will be assessed on a priority basis. Non-urgent or incomplete applications may take up to 2-3 weeks or longer in some cases.

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 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 to under the Workplace Safety and Insurance Act (WSIA).

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 new 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.

Provider Facility Payment Unit

Health Services Branch

1055 Princess Street

P.O. Box 168

Kingston, ON K7L 5V1

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 sent to the patient.

The ministry will continue to re-examine an application as long as new 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 there is no additional relevant information to provide, an appeal of the ministry's decision may be made 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