12/15/2025
Canadian Life and Health Insurance Association (CLHIA) and the Canadian Association of Optometrists have been continuing to discuss a collaborative approach to protecting patients and benefit plans. While optometrist's continue to advocate for the simplest solution for submission and verification of eligibility and payment, not all insurances have functioning optimal solutions.
To ensure maximum compliance with all Health Insurances we will no longer able to check for patient eligibility online with the exception of Green Shield since the others do not have a unique option to check eligibility without submitting at the same time.
In the past we would submit the assumed amount and then reverse the claim submission and resubmit when services were rendered. This is onerous on staff and if cases were not reversed appropriately then we run the risk of falling foul to the CLHIA fraud standards and risk being removed from being able to submit directly on a patients behalf. Insurance cannot be used as a deposit on products or services.
We will continue to receive updates from the CAO and hope to be able to resume eligibility checks once CLHIA portals allow for a simple process. Patients should be able to check on their insurance provider aps to determine if they are eligible prior to scheduling or receiving services.
CLHIA and the CAO want to remind users and providers to continue to avoid risky practices which can jeopardize the client or the provider such as Billing Misrepresentation (ie. using a family members insurance for another family member's service), Adjusting service dates or Invoicing for non-prescription sunglasses.
Patients are reminded that benefit plans vary and it is their responsibility to confirm eligibility and limits before incurring expenses. Providers are reminded that "Use it or Lose it" messaging is inappropriate as it may encourage unnecessary use of benefits.
If you have any questions or concerns please call, text or DM the office and we will attempt to resolve any concerns or direct you to your insurance provider for more information.