Green Shield Canada Update
 
New Claims Rules for Orthotics and Orthopedic Footwear Coming January 1,2014.
 
Orthotics and orthopedic footwear benefits are meant to provide coverage for plan
members diagnosed with medical conditions that affect their feet,and who require
specialized footwear to treat their condition or to assist with mobility. In other
words, orthotics and orthopedic footwear must be medically necessary in order to
be eligible for reimbursement.
 
Unfortunately, orthotics and orthopedic shoes tend to be overly prescribed and
improperly dispensed by providers and retailers who are not foot specialists and for
non-medically necessary purposes that are not intended to be covered under benefits
plans. Many providers and retailers are selling shoes that are marketed as
“orthotics” or “orthopedic”, but do not meet benefit eligibility requirements. While
this footwear may provide plan members with some comfort and support for their
feet, they are not medically necessary and are not eligible expensesunder the benefits
plan.
 
Starting on January 1, 2014, Green Shield Canada (GSC) is implementing a
new standard adjudication policy for orthotics, orthopedic footwear and custom
footwear claims. Plan members who submit claims for these items will be required to:
 
  • Submit new documentation with each claim;
  • Ensure that their provider is eligible; and
  • Meet specific medical criteria. Only those orthotics, orthopedic footwear, and custom footwear that                                                                              are prescribed to treat arecognized medical condition will be eligible for reimbursement
Starting on January 1, 2014, the following claims submission rules will be applied:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
What’s not covered?
 
Orthotics purchased solely for comfort, for sports or recreational activities, stock
items, off-the-shelf and prefabricated devices, soles or inserts (e.g., Dr. Scholl’s) are
not eligible. Having plan members walk on an ink pad or pressure pad to provide a
prefabricated sole or insert is not considered custom made orthotics. Off-the-
shelf walking or sports shoes marketed as orthopedic, sandals, comfort shoes without
prescription for a medical condition, shoes purchased specifically for sports or
recreational activities are not eligible. Claims for these types of devices or footwear
will be denied.
 
The new adjudication information will be noted in the Plan Member Online Health
& Dental Claims Centre and on your Explanation of Benefits forms starting
December 1, 2013.
 
 
 

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West Toronto Foot & Ankle Clinic Inc.

781 The Queensway, Unit NToronto, ON M8Z 1N4