Français For eligible beneficiaries, while temporarily away from Newfoundland and Labrador, MCP will cover some of the costs of insured services that are specified under the Medical Care Plan and the Hospital Insurance Plan. However, the full costs of medical services received in another
province, territory or country may not be covered, especially outside of Canada. MCP will not cover any cost for medevac or ground and air ambulance outside the province, and most likely these services will not be provided freely by the province, territory, or country in which you are travelling. The costs of medical transportation, emergency assistance, and other health care services outside Newfoundland and Labrador can be very significant and may not be fully or even partially covered
by MCP, even within Canada. Travelers are strongly advised to obtain additional insurance for these services from a private insurer prior to leaving the province, for any length of time. If you are leaving the province for more than 30 days, an Out-of-Province Coverage Certificate should be obtained in order to ensure that your MCP coverage will not expire.
Note: MCP may require a copy of an applicant’s Notice of Assessment for the most recent tax year indicating Newfoundland and Labrador as the applicant’s province of residence before granting extended out of province coverage. Rates Payable-Services Obtained in CanadaInsured medical services obtained in other provinces and territories are payable at the rates established by the medical care plan in those jurisdictions. This means that, with some exceptions which are outlined below, you will not have to pay for any portion of the physician’s charges for insured medical services. There are several situations where you may receive a bill for services. These are as follows:
With the exception of Quebec, all provinces and territories have an agreement whereby physicians in each province or territory submit claims to their local medical care plan for services provided to residents of the other Canadian jurisdictions. The fees for the services are paid to the physician and the costs are then charged to the resident’s home plan. Rates Payable-Services Obtained Outside CanadaWith certain exceptions, claims for insured medical services obtained outside Canada are paid at Medical Care Plan (MCP) rates, which are the rates paid to Newfoundland and Labrador physicians. When the amount billed exceeds the amount payable, payment of the difference is the patient’s responsibility. It should be noted that the costs of medical care in certain countries, particularly the United States, are significantly higher than the rates paid by Medical Care Plan (MCP). It is strongly recommended that additional travel insurance be obtained whenever traveling outside Canada. For more information on travel insurance, please contact one of the insurance companies listed in the yellow pages of our local Telephone Directory under Insurance – Life and Health. A) Rates Payable-Services Available in Newfoundland and LabradorClaims for insured medical services obtained outside Canada, that are available in Newfoundland and Labrador, are paid at Medical Care Plan (MCP) rates, which are the rates paid to Newfoundland and Labrador physicians. When the amount billed exceeds the amount payable, payment of the difference is the patient’s responsibility. B) Rates Payable-Services Available in Canada but not in Newfoundland and LabradorInsured medical services obtained outside of Canada which are not available in Newfoundland and Labrador but are available in another province are payable at the rates established by the medical care plan in that province. When the amount billed exceeds the amount payable, payment of the difference is the patient’s responsibility. C) Rates Payable-Services Not Available in CanadaIf you are planning to have insured medical treatment which you think may not be available in Canada, and if you wish to claim reimbursement of related medical costs through Medical Care Plan (MCP), you must ask your physician to request prior approval from Medical Care Plan (MCP) before obtaining such treatment in another country. By doing so you will be made aware in advance of the rate at which your medical bills will be reimbursed. If you are granted prior approval based on the unavailability of the services in Canada, the Medical Care Plan will provide coverage for medically necessary physician services. Payment will be in the currency of the country where the services are received provided the rates are deemed to be fair and reasonable as determined by the Department of Health and Community Services. Prior approval is mandatory to receive payment at rates higher than those published in the Medical Care Plan (MCP) or other provincial physician fee schedules. If a patient opts to travel outside the country for medical service/treatment and prior approval has not been granted, payment will be in accordance with the established rates outlined in A) or B) above, and any balance remaining is the responsibility of the patient. Claim Submission RequirementsIf you have been treated by a physician in Canada who is not participating in the interprovincial arrangement, or have obtained services which are excluded from the agreement, it will be necessary for you to submit an Out-of-Province Claim Form. This claim may be submitted on your behalf by the physician, in which case you will be asked to sign the form. If the physician elects not to submit a claim on your behalf or you obtain medical services outside Canada, you should obtain letterhead billing which contains an itemized statement of the charges and services. This information is required so that we may substantiate and assess your claim. You will then be required to submit an Out-of-Province Claim Form, accompanied by the letterhead billing. Which is a review of the appropriateness and necessity of care provided to patients prior to administration of care?The utilization management (or utilization review) is a method of controlling healthcare providers and quality of care by reviewing the appropriateness and necessity of care provided to patients prior to the administration of care.
Which is a review for medical necessity of tests and procedures?Health Insurance Claims Chapter 3. Which of these is responsible for reviewing health care provided by managed care organizations?CMS is responsible for reviewing and approving state requests to implement managed care under these authorities. All Medicaid managed care programs, regardless of authority, are subject to the provisions of Section 1932 and 42 CFR 438 unless specifically waived.
Which means the patient and or insured has authorized the payer to reimburse the provider directly?assignment of benefits. Which means that the patient and/ or insured has authorized the payer to reimburse the provider directly? Medicaid Summary Notice.
|