Usually, Extended Health Care expenses are paid in full by the member first, and the original paid receipts are submitted for reimbursement. Under certain circumstances, some insurers will arrange direct payment with the hospital or practitioner; however, such requests are usually only accepted with large claims causing financial hardship to the member.
To submit an Extended Health claim, members must complete a Medical Expenses / Extended Health Care claim form and attach all original receipts for items being claimed. All dates, amounts, drug identification numbers and drug names must be entered where applicable.
Claims should be submitted within 90 days after the end of the calendar year in which expenses were incurred. If coverage has been terminated for any reason, employees have 90 days from their termination date to submit any eligible claims, or as defined in your Benefits Handbook(s).
If your plan includes a Pay Direct Drug Card, expenses for prescription drugs, and testing supplies for diabetics, will be paid directly to the pharmacy so there is no out of pocket expense to your employees. The member simply shows the pharmacist their Pay Direct Drug Card and the pharmacist will charge them only for amounts not covered by the card (e.g. deductibles, if applicable).
The Pay-Direct system is used for immediate claims adjudication of eligible prescription drugs purchases only. Member oneCards indicate the Pay-Direct information required at most Canadian pharmacies.
- oneCards are automatically re-issued if a member’s last name or ID number changes.
- Pay-Direct drugs can only be accessed within Canada.
- If a member’s drug card is declined at the pharmacy, advise the member to verify the spelling of their name and the date of birth entered by the pharmacy, as this information must match the GroupHEALTH system in order for the claim to be paid.
- If an member’s oneCard is lost or stolen, contact GroupHEALTH immediately.
Online claims submitted through the Member Portal may be selected for audit. This can be due to random audit guidelines, or adding a new provider or other plan changes. If a claim is selected for audit, the member will be required to upload the invoices and receipts, and claims payment may be delayed by up to 8 days.