Coverage

This area covers the establishment, maintenance, and retrieval of coverage information associated with a member. There are three types of coverage managed by the BPCS system:

  • Private coverage is coverage issued by payers other than the Government of Ontario. It is tracked because private coverage impacts coordination of benefits, as well as influencing the deductibles paid for certain public plans. Private coverage is maintained only as part of the Trillium 'Family Coverage' application process, but can be queried alongside other coverages. Recipients that do not have Trillium coverage will not have any record of their private coverage information recorded.

  • Public individual coverage is coverage offered by the Government of Ontario whose enrollment and elligibility process only requires information about the individual receiving coverage and does not require information about others in their household.

  • Public household coverage is coverage where the benefits acrue to, and/or the enrollment process requires knowledge of information about, individuals living in the same household as the initiating beneficiary. Processing of these coverages is more complex and involves transactional interactions that take in information about the household, family members, consent, income, private coverages, etc. Some of the interactions below apply to all three coverage types. Others apply to only specific types of coverage. Each will declare what coverage types are addressed. There are specific rules for which types of receipts are allowed to appear as items within a single Claim. Specifically:

  • If a patient has Trillium coverage, then all receipts that have dispense dates falling within the Trillium family period must be submitted in a Claim specific to that Trillium period. (This is true even if the patient's coverage isn't active on the receipt date, so long as they are part of the family and the family coverage is active.) Receipts for other family members that are also coveraged may also be submitted, but no receipts outside the coverage period may be submitted.

  • If there are receipts for multiple Trillium coverage periods, each period will need its own claim.

  • If a receipt does not fall within a trillium coverage period, the receipt must be submitted in a Claim for a single patient - even if the patient has coverage under the Senior's program.

If these rules are not followed, the Claim will be rejected with an OperationOutcome when submitting the Claim and will result in a 'warning' OperationOutcome if holding the Claim. For this reason, clients should check receipts on entry to ensure that receipts are being grouped into appropriate Claims.