Responsibility of the Clinic

1. Our clinic is responsible for recommending appropriate products or services based on medical necessity and,
2. Providing the product/service as well as the required documentation for insurance submission.
3. Where coverage details are unknown, you are encouraged to obtain a predetermination/quote to determine eligibility prior to proceeding. We are happy to provide this.

Responsibility of the Client (you)

1. Clients are responsible for understanding their health benefit plan details, including which products or services are covered, important renewal dates, available/remaining coverage, and requirements such as needing to obtain a physician or nurse practitioner prescription if needed.
2. Where coverage details are unknown, you are encouraged to ask for a predetermination/quote to determine eligibility before deciding to proceed with products/treatments. You must submit this to your insurer and let the clinic know the outcome and how you would like to proceed.

Understanding your benefit plan is an important part of managing your health care journey. Every plan is different—coverage amounts, eligible services, and renewal dates can vary widely between providers and even between individuals on the same plan. Taking a few moments to review your policy details or speak directly with your insurance provider can help you make informed decisions when presented with a treatment plan, avoid unexpected costs, and feel more confident when accessing care.

It’s also important to be aware of your plan’s renewal date, as this determines when your benefits reset. Some plans renew annually based on the calendar year, while others follow a different schedule tied to your employer or enrollment date. Knowing this timeline can help you plan treatments and make the most of your available coverage before it expires.

While healthcare providers are always happy to support your care and answer general questions, the responsibility for understanding and managing your specific benefit plan ultimately rests with you, the client. Insurance companies are the best source for accurate, up-to-date information about your coverage. By staying informed, you help ensure a smoother experience for yourself and allow your ethical lower extremity care team to focus on what matters most—delivering the best possible care. For more information, contact your local BioPed Footcare clinic at www.bioped.com/locations.

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What Is Third-Party Insurance and How Does It Work?

In Canada, third-party insurance coverage typically refers to extended health benefits that are offered by your employer or purchased privately. It is provided by an organization other than the government, and covers items and services which are typically not covered by the government insurance. Third-party insurance varies widely from plan to plan and from company to company but may include custom orthotics or paramedical practitioner coverage.

Does Third-Party Insurance Cover Orthotics?

In many cases, custom orthotics are covered by most third-party plans, but they typically require certain criteria to be met. These criteria can include any or all of the following:

1. Medical Prescription: A prescription from a medical doctor or other recognized professional (Chiropodist, Nurse Practitioner) that names your condition (the reason you require the orthotics) indicating medical necessity of the custom orthotics.
2. Proper Documentation: This would include the gait analysis and biomechanical assessment confirming the medical necessity, as well as the breakdown of orthotic manufacturing process (materials used and how the cast of the feet were taken).
3. Detailed Invoice: The date of dispense, breakdown of the cost of the orthotics and the location of the manufacturing of the orthotics.
4. Proof of a Qualified Professional: The BioPed Pedorthist or Chiropodist’s certification number must be present on the paperwork.

Tips for Clients Navigating Insurance Coverage

Before your appointment, you should do some homework to create a smoother process.

Call your insurance provider before your appointment: Ask if you have custom orthotics coverage and whether you require a medical prescription with diagnosis. You’ll also want to know what type of healthcare professional can assess and dispense the orthotics per your plan. Finally, you’ll want to learn what amount your coverage is for. Some plans have a maximum limit and a frequency date. Even where coverage is present, you’ll likely have some out-of-pocket expenses. Most plans do not cover 100%.

Once you receive your new custom orthotics, keep all receipts and documentation. Most plans require detailed proof, and BioPed clients receive a full package to help streamline the claim.

We work closely with many insurance plan providers and will help you navigate the claim submission process and provide a quote where it is necessary to predetermine coverage. We confirm your medical need for custom orthotics through a detailed assessment process and issue all required paperwork for insurance claim submission to ensure a smooth, simplified process. Insurance reimbursement direct to the plan member who submits – you! – is typically expedited.

The post Navigating orthotics insurance coverage in Canada: What you need to know. appeared first on Relieve Foot Pain & Leg Pain.