Prior approval from the Ministry of Health and Long-Term Care is required in order for you to receive funding for OHIP insured hospital and medical services out of country (OOC). Written approval MUST be received from the ministry before OOC health services are received.
Application forms must be submitted to the ministry by your Ontario physician before any OOC hospital or medical services are rendered. If your physician determines that you require OOC hospital or medical treatment, your physician must submit a Prior Approval Application to the ministry for consideration. With limited exceptions, applications must include written confirmation from a specialist that the regulatory conditions for funding are satisfied.
The following new Out-of-Country Prior Approval application forms are now available.
These new forms are specific to the type of out-of-country service being requested and are intended to replace the existing form. When applying for funding for out-of-country health services on your patient’s behalf, please complete the application form that is appropriate for the out-of-country service being requested.
Completed application forms may be mailed to the ministry at the address provided at the top of the form, or sent by fax to: 1-866-221-3536 or 613-536-3181.
Please note that the ministry will continue to accept out-of-country prior approval applications submitted using the old form until October 31, 2010. After that time, the old forms will be considered obsolete and you will be contacted to resubmit an application to the ministry using a new application form.
When your application for OOC Prior Approval has been processed by the ministry, a decision letter will be sent to your Ontario physician and a copy sent to you. Your letter will clearly outline what service(s) have been approved, the facility where the service(s) are to be provided and the approved cost of the service(s).
The decision letter is based on the medical documentation provided with your application. If your circumstances change, a new prior approval application may be submitted to the ministry by your Ontario physician requesting new treatment and/or services as well as the proposed OOC physician/facility for consideration.
If you do not receive prior approval from the ministry before medical services are rendered outside of Canada, you will be responsible for any and all costs associated with this treatment and your medical expenses may not be funded by OHIP.
Prior Approved Services : (services that are provided outside Canada under special arrangements made prior to the medical services being received). The requested OOC services may be OHIP insured, if the "Prior Approval Application for Full Payment of Insured Out of Country Health Services" established that the services and treatment being requested are :
Note : Even when medical services are prior approved, you are still encouraged to purchase additional private medical insurance and fully understand what your policy covers.
In the case of prior approvals, the ministry only covers costs for prior-approved medical services. Expenses incurred for non-medical services such as travel, accommodation and meals (except where included as part of insured hospital services) are NOT covered by OHIP.
Treatment that is generally accepted in Ontario as experimental, for research or a survey, including clinical and drug trials are also not covered by OHIP.
If you require OOC hospital or medical services as the result of a work-related accident, the prior approval process is not applicable and a 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).
For more information contact :
Health Services Branch,
Provider Payment Programs – Out of Country Program
Negotiations and Accountability Management Division
Ministry of Health and Long-Term Care
370 Select Drive, P.O. Box 168
Kingston, ON K7M 8T4
Tel : 1-888-359-8807
E-mail : OOCPriorApprovalInq.firstname.lastname@example.org
Fax : 1-613-536-3184
You and your Ontario doctor submitted a “Prior Approval Application for Full Payment of Insured Out-of-Country Health Services” and funding was denied. What can you do?
You may :
1) Internal Review Process (IRP )
When requested to do so, ministry staff conduct internal reviews on your behalf. We strongly suggest you and your doctor make sure that you have provided as much relevant medical information and documentation as possible in support of your denied application for funding.
These reviews can be requested in addition to a hearing before the Health Services Appeal and Review Board (HSARB ) or they can be requested instead of a hearing before the HSARB . The ministry will continue to conduct internal reviews of your prior approval application as long as relevant additional information is provided.
To request an internal review of your prior approval application, please contact the ministry in writing at the following address :
Ministry of Health and Long Term Care
Health Services Branch
370 Select Drive
P.O. Box 168
Kingston, ON K7M 8T4
Or by telephone: 1-888-359-8807
To support your request for an internal review, we strongly recommend that you (or your Ontario physician) provide additional information and/or medical documentation to the ministry that may not have been provided previously. This information can be sent to the ministry by mail (to the address provided above) 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 Ontario 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 your application for OOC prior approval has been denied by the ministry, either initially or following an IRP and you have no additional relevant information to provide, you may request an appeal of the ministry’s decision to the Health Services Appeal and Review Board
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 : email@example.com
Call ServiceOntario, Infoline at 1-866-532-3161
In Toronto, 416-314-5518
In Toronto, TTY 416-327-4282
Hours of operation : 8:30am - 5:00pm