Overview
The Out-of-Country Health Services Committee (Committee) reviews applications for payment of expenses for insured services and insured hospital services to be provided outside of Canada when those services are not available in Canada and when all other appropriate health service options in Canada have been fully exhausted.
A physician or dentist must apply on behalf of the patient.
Eligibility
Prior approval is required for all elective (non-emergency) medical services.
Applications must meet all of the following requirements as set out in the Out-of-Country Health Services Regulation:
- The resident has valid health insurance coverage under the Alberta Health Care Insurance Plan.
- The resident has endeavoured to receive the services in Canada, the services are not available in Canada and all other appropriate options in Canada have been exhausted.
- The services must be medically necessary and supported by clinical documentation from the applying Alberta physician or dentist.
- The services must be medical, oral surgical, or hospital services insured under the Alberta Health Care Insurance Plan (AHCIP) or the Hospitalization Benefits Plan.
- The services will be provided in a manner that accords with accepted standards of practice in Alberta.
- The services are not part of a research study or clinical trial and are not experimental.
Submitting an application for payment of expenses does not guarantee approval. The Committee bases all decisions on current legislation and the medical and clinical information provided.
Expenses
Some expenses not approved by the Committee may be partially covered by the AHCIP.
Learn about coverage outside Canada.
Ineligible expenses
Services or expenses not eligible for payment of expenses include, but are not limited to:
- meals
- accommodations or lodging costs
- travel medical insurance
- take-home drugs
- medical equipment or supplies
- publicly funded services (services provided by Alberta Health Services)
- mental health services
- behavioural disorders
- addiction treatment
Application process
An application must be submitted to the Out-of-Country Health Services Committee by an Alberta physician or dentist on behalf of their eligible Alberta patient. The application must meet all of the eligibility requirements.
Patients are not permitted to self-refer or submit application documentation
Payment of expenses is limited to the cost of the insured physician and insured hospital services provided outside of Canada with respect to the approved service.
Alberta physicians and dentists: Learn how to apply
Application review
The Committee Chair (Chair) has the authority to screen out and deny applications that do not meet the following non-medical requirements:
- the application was submitted more than 365 days after the out-of-country health services were received
- the patient is not a resident of Alberta and not registered under the AHCIP
- the applying physician or dentist is not registered to practice in Alberta
If any of the above requirements are not met, the Chair will send a letter to the applying Alberta physician, with a copy to the patient, outlining the decision to screen out or deny the application. If the above requirements are met, the Committee Chair will review the application to determine whether it contains enough information for the Committee to make a decision.
If additional information is required, the Committee Chair will send a letter to the applying Alberta physician or dentist requesting the additional information.
Once the application contains enough information to declare it “complete” by the Chair, it will be forwarded to the Committee for decision within 60 business days.
Applications are considered complete when:
- all the required information has been submitted by the applying physician or dentist
- the Committee Chair has notified the applicant in writing that the application is complete
- the application has been scheduled for review at an upcoming Committee meeting
Committee decisions
Within 20 business days of making its decision, the Committee sends a written copy of its decision with reasons to the applying Alberta physician or dentist with a copy to the Alberta resident on whose behalf the application was submitted.
Each application is reviewed on its own individual merits and as a unique circumstance for an individual patient. Decisions are made on a case-by-case basis, and within the parameters of current health legislation.
All decisions are based on the medical evidence provided and the Committee does not treat previous decisions as binding precedents.
If the application is approved in whole or in part, payment of expenses to the extent allowed by the Out-of-Country Health Services Regulation will be provided. The decision letter provides all the necessary information to make arrangements for the out-of-country service.
Medically urgent applications
For emergency health services, the Alberta physician or dentist must apply to the Committee prior to the patient receiving the services or apply to the Committee for reimbursement no later than 365 days after the services are received.
The circumstances to expedite an application are extraordinary, and compelling medical evidence must be submitted in support of an application where an expedited decision is requested.
Contact the Committee
Connect with the Office of the Out-of-Country Health Services Committee:
Hours: 8:15 am to 4:30 pm (open Monday to Friday, closed statutory holidays)
Email: [email protected]
Address:
Chair, Out-of-Country Health Services Committee
PO Box 1360, Station Main
Edmonton, Alberta T5J 2N3
Appeal an OOCHSC decision
Decisions made by the Committee Chair or the Committee can be appealed to the Out-of-Country Health Services Appeal Panel (Appeal Panel) which operates separately from the Committee.
The Appeal Panel reviews the decision, all the materials originally submitted as part of the application to the Out-of-Country Health Services Committee, mail tracking information and the appeal. The Appeal Panel is not authorized to review new information.
Note: the Appeal Panel does not independently come to a decision about an application. The Appeal Panel assesses the decision-making process and decision made by the Committee Chair or Committee.
The Appeal Panel will evaluate the Committee’s process and decision to ensure the Committee addressed the facts, issues and evidence the Committee had when making the decision. The Appeal Panel will also evaluate whether the Committee’s decision falls within a range of acceptable potential outcomes and whether the reasons for the decision are clear and understandable.
The Appeal Panel also reviews the Committee’s decision to assess jurisdictional and procedural fairness.
Submit an appeal
The Alberta resident or an Alberta physician or dentist may submit an appeal to the Appeal Panel.
A written notice of appeal must be received by the Appeal Panel within 60 business days of receiving the Committee’s decision.
Mail or fax the appeal to:
Out-of-Country Health Services Appeal Panel
PO Box 1360, Station Main
Edmonton, Alberta T5J 2N3
Fax: 780-644-1445
Phone: 780-638-3899
Appeal decisions
The Appeal Panel has 60 business days from the date it receives the written notice of appeal to make its decision.
The Appeal Panel may uphold or overturn (in whole or in part) the Committee decision to deny payment of expenses.
Once a decision has been made the Appeal Panel will notify the person who submitted the appeal of its decision in writing within 20 business days.
All Appeal Panel decisions are final.