416-465-8737

 

TORONTO CHIROPODIST, D.Ch., B.Sc., PODIATRIC MEDICINE

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What isn’t covered?

  • Off-the-shelf, non-orthopedic footwear (e.g. comfort shoes and sandals)

  • Shoes purchased specifically for participation in sports or recreational activities (e.g. cleats)

  • Off-the-shelf, non-custom or pre-fabricated orthotics (e.g. Dr. Scholl’s insoles)

    Claim submission requirements effective February 1, 2013

    New claim submission requirements for orthopedic shoes and custom- made foot orthotics include:

    Prescription requirement

    The orthopedic shoes and custom-made foot orthotics described above are generally covered under a benefits plan when they are considered to be reasonable treatment of disease or injury, and when prescribed by one of the following health care providers:

  • Physician (MD);

  • Chiropodist;

  • Podiatrist; or

  • Orthopedic surgeon.

    The prescription must set out the medical diagnosis necessitating the supply prescribed. Prescriptions outlining symptoms rather than a medical diagnosis will not be sufficient.

    Claims for custom-made orthopedic shoes will also be required to include a lab bill that includes:

  • Details of the casting technique used; and

  • A description of the process and material used to fabricate the shoes.

    Claims for custom-fitted or pre-fabricated (off-the-shelf) orthopedic shoes will also be required to include:

  • The brand name and model of the shoes;

  • A description of each modification made to the shoes (if applicable);

    and

  • A breakdown of the cost of the shoes and each modification (if

    applicable).
    Claims for a custom-made foot orthotic will also be required to include:

  • A copy of a detailed biomechanical examination or gait analysis

  • Details of the casting technique used

  • A detailed description of the type of orthotic provided

  • A breakdown of the charges for the orthotic

    Why is our process changing?

    Generally, medical professionals, including foot care specialists, advise that generally a patient’s medical condition can be accommodated with well- constructed retail footwear or orthotics. Therefore, many patients do not require custom-made or pre-fabricated orthopedic shoes.


Further, the dispensing of orthopedic shoes and orthotics is not itself a regulated act and these supplies can be dispensed by a variety of health care providers and other individuals. As a result, there is no standard billing practice for these supplies and marketing and billing varies by the dispenser. Based on recent activity of some providers and the results of investigations we have conducted, we’ve determined it necessary to gather additional information with claim submissions to help determine whether a claim qualifies for coverage.

There are many different types of shoes marketed as “orthopedic,” as well as many different types of in-shoe devices referred to or marketed
as “orthotics.” Advances in shoe design technology and widespread availability of these products in an unregulated market can make it confusing for plan members to obtain orthopedic shoes or orthotics eligible for coverage under their plan. The new claim submission requirements are intended to help clarify the claims requirements for plan members and ensure claims are adjudicated on a timely basis, and in accordance with your benefits plan.

Is it possible that claims for which benefits were paid in the past won’t be considered eligible for coverage in the future?

Yes, some claims for which benefits were previously paid may now be determined to be ineligible when documentation included in the new claim submission requirements is received. Great-West will be providing a notice to providers of orthopedic shoes and custom-made foot orthotics to explain our new claim submission requirements.

Is this consistent handling in the industry?

Yes. The Canadian Life and Health Insurance Association (CLHIA), whose membership accounts for 99 per cent of the life and health insurance in force in Canada, recently published a document which is posted on their public website to help consumers understand claims for footwear and orthotics. This document can be found on the CLHIA website at: 

Comments:

Academy Clinics has a special interest in high quality custom orthotics.

 

416-465-8737

Toronto, ON Chiropodist
Academy Foot and Orthotic

752 BROADVIEW AVENUE
Toronto, ON M4K 2P1 

Across from the Broadview Subway
Professional  Family  Foot  Care

PROFESSIONAL
FOOT CLINIC

CHIROPODIST / FOOT SPECIALIST,  B.Sc. PODIATRIC MEDICINE / ACADEMY FOOT & ORTHOTIC CLINICS, 752 Broadview Ave , Toronto ON, M4K 2P1 416-465-8737