Direct Billing for Physiotherapy, Chiropractic and RMT in Toronto

How Direct Billing Works

Direct billing allows a healthcare clinic to submit an insurance claim for an eligible service on the patient’s behalf.

The usual process is:

1. You provide your current insurance information and consent to the claim submission.
2. You receive the service from the appropriate practitioner.
3. Core Wellness Centre submits the eligible claim.
4. Your insurer reviews the claim and provides a response.
5. You pay any amount that the insurer does not cover.

Some insurers pay the clinic directly. Others may pay the plan member or require the patient to submit the claim. The insurer controls this process.

Services That May Be Eligible

Direct billing may be available for eligible services provided by:

• Physiotherapists
• Chiropractic care
• Registered massage therapists

Coverage for osteopathy and other clinic services depends on the insurer, the plan and the practitioner’s recognized professional association. Contact your insurer before booking if you are uncertain about eligibility.

A practitioner’s recommendation is based on your health history, assessment findings, needs and goals. Insurance coverage does not determine which service or treatment is clinically appropriate.

Professional Information

Dr. Kris Dorken, DC, is registered to practise as a chiropractor in Ontario and is a member of the College of Chiropractors of Ontario.

Physiotherapy and registered massage therapy services are provided by professionals registered with their respective regulatory colleges in Ontario.

Claims are submitted under the registration information of the practitioner who provided the service.

What to Bring to Your Appointment

Please bring:

• Your insurer’s name
• Your policy or plan number
• Your member or certificate number
• The plan holder’s name and date of birth
• Your relationship to the plan holder
• Information for a second insurance plan, if applicable
• A referral or prescription if your plan requires one
• Any claim forms or insurer instructions you have received

Providing this information does not guarantee that the insurer will accept the claim.

Confirm Your Coverage Before Your Visit

Insurance plans differ between employers, associations and individual members. Two people insured by the same company may have different coverage.

Ask your insurer:

• Is this healthcare service covered?
• Is this practitioner eligible under my plan?
• Do I need a medical referral?
• What is my annual maximum?
• Is there a per-visit limit?
• Do I have a deductible or co-payment?
• How much coverage do I have remaining?
• Does the plan accept direct electronic claims?
• Will payment be sent to the clinic or to me?
• Does the plan require additional documentation?

Core Wellness Centre may help explain a claim response, but only your insurer can confirm your benefits and make a coverage decision.

Which Insurance Companies Can Be Direct Billed?

Core Wellness Centre may be able to submit eligible claims to participating extended health insurers.

Insurer participation, online systems and individual plan rules can change. Contact the clinic with the name of your insurer and the service you intend to book. The clinic can tell you whether electronic submission is currently available.

Even when electronic submission is available, the insurer may:

• Pay the full eligible amount
• Pay part of the claim
• Apply a deductible
• Pay the plan member instead of the clinic
• Request additional information
• Ask for manual submission
• Decline the claim

Do I Have to Pay at the Appointment?

You must pay any amount that is not paid directly to the clinic.

You may need to pay the full appointment fee when:

• Your insurer’s system is unavailable
• The insurer cannot confirm coverage
• The claim requires manual review
• Payment is sent directly to you
• Your coverage limit has been reached
• The service or practitioner is not eligible
• Required information is missing
• The claim is declined

The clinic will provide an appropriate receipt when required so you can submit the claim yourself.

Coordination of Benefits

If you have coverage under two insurance plans, coordination of benefits may be available.

The order of submission depends on who holds each plan and the insurer’s rules. In some cases, the first insurer processes the claim before the remaining balance can be submitted to the second insurer.

Bring information for both plans. The clinic will let you know whether it can submit both claims electronically or whether you must submit the second claim yourself.

Direct Billing for Dependants

Direct billing may be available for a spouse or dependant covered by an eligible plan.

The clinic may need:

• The plan holder’s information
• The dependant’s information
• The relationship between the patient and plan holder
• Consent or authorization required by the insurer

The insurer determines whether the dependant and service are eligible.