The program can approve funding for tests not available in B.C. when there is sufficient evidence that the test is medically necessary to change patient management. The completed application form should provide sufficient evidence to support medical need. Include additional evidence in the form of a medical consult note, previous in-province tests, or other relevant information, with the application form. We make each funding decision on a case-by-case basis, without precedent, based on the specific patient presentation and/or clinical indication.

The program does not fund tests managed and funded by a specific provincial program, interprovincial reciprocal billings, fee-for-service laboratory testing, or for tests covered by health authority global funding (including lab tests associated with most acute care services).

All relevant in-province testing must be completed before submitting a funding application.

• One application form per patient and one vendor laboratory (i.e. multiple tests can be requested for testing at the same laboratory)
  
• The signed patient consent form
  
• All additional supporting information, including results of all relevant in-province tests, or a medical consult note
  

‎A thoroughly completed application makes it more likely that we can reach a decision quickly.

We will review the application to determine that the patient presentation meets all the requirements for funding approval. Your responses help to identify alignment with funding guidelines and clearly demonstrate how the test result influences patient management.

Incomplete applications or insufficient information may delay decision-making or, in some cases, may mean that we will deny funding until you have clarified the information.

Out-of-province funding reviewers have technical expertise in laboratory medicine and genetics. This team will review and make decisions on each application according to program guidelines, on a case-by-case basis. We may engage an adjudication committee of additional experts for appeals or complex cases.

The average time from application receipt to decision is under 72 hours, with most applications being decided in less time.

Only those applications requiring additional funding for expedited testing qualify for URGENT processing:

• the patient is either pregnant or acutely ill (i.e. admitted to the hospital) AND
• the test results are required for treatment decisions within 2 weeks of the application submission.
  

Send specimens approved for funding for an expedited turnaround time to the testing laboratory as soon as you receive the approval letter.

An expired approval letter is not cause for an urgent review. We will review these letters in the order we receive them.

It is difficult for us to incorporate changes once we have received the application.

You can ask the program to cancel the application so that you may submit a new one. Otherwise, upon receipt of the decision letter, please contact program staff to cancel the funding and resubmit a new application, CLEARLY indicating:

1. the application number you want cancelled, and
2. that testing will not proceed on the previous decision.

If we approve the changes, we need confirmation that you have destroyed the active decision letter before we can issue a new decision letter, to prevent inadvertent use of a now-cancelled letter. We will only honour the most recent decision letter for payment to the vendor.

Submitting a new application to reflect changes to an application is different from an appeal. Appeals require additional information to support another review of a denied application.

We approve additional funding on a case-by-case basis. We will consider approval when there has been a change to the patient's presentation, or enough time has passed that technology or knowledge has improved substantially.

Reference the previous application number or provide a copy of previous results, and provide documentation that supports the need to fund additional tests (e.g. test results, new consult note, etc.).

The beneficiary must have an active B.C. personal health number (PHN) at the time of the application and at the time of service. The service date is the date when the laboratory initiated testing. The requesting practitioner will be responsible for testing completed on a patient whose PHN is not active at the time of service.

The OOP program has no ability to reimburse a requesting practitioner, patient, or health authority for any services.‎

We typically decide funding applications less than 72 hours from receipt of the application. Applications that are complete and contain all the necessary information are easier to review quickly. Incomplete applications, applications with insufficient information, or those with borderline presentations, take longer to adjudicate.

Once the program reviews the funding application and supporting documents, we will mail a decision letter* to the requesting practitioner. The requesting practitioner will contact the patient regarding the funding decision.

If you have not received a decision letter within the expected timeframe, contact the program at ooc@phsa.ca to ask for the status of your application. Please do not submit duplicate applications.

*We will only fax urgent funding application decisions. We will send all other application decisions to the requesting practitioner by mail.

‎The three-month timeframe allows the referring practitioner time to coordinate the patient’s specimen collection.

This window ensures funding is accessible and allocated in an equitable and timely manner, when medically necessary testing is required. It also keeps the program fiscally responsible to forecast program expenditures every month.

The program does not allow extensions for an expired approval letter.

‎If a sample cannot be collected within 3 months of the date of approval, you must submit a new application, which will be subject to the program’s current guidelines at that time. We may request new information when you re-apply, based on how much time has passed since the last approval, or on evolving approval guidelines.

Only resubmit an application after the approval letter has expired. Provide the original application number, and indicate:

1. that it is a resubmission, and
2. that testing has not proceeded under the previous approval.

The program will not fund duplicate testing for the same patient, which may result in the patient or provider having to pay.

We will cancel an application if:

• The patient’s personal health number (PHN) is invalid or inactive at the time the application is submitted
  
• You have not submitted the consent form, the form is not signed, or you have used an incorrect version of the consent form
  
• You have not submitted other required documentation (e.g. consult note, previous test result, etc.)
• The application is illegible or incomplete

If the patient's presentation does not meet the funding guidelines or the application has not demonstrated how it meets the guidelines, we may deny funding. Refer to the Guidelines (PDF) for further details.

We will identify the reasons for denying funding in the decision letter. Please read the decision letter in its entirety.

Incomplete or unclear applications may lead to a denial.

Examples:

• The requested test was not clearly identified (Question #5)
• The impact on patient management is unclear or marked as having no impact, without a sufficient explanation provided to justify funding the test (Question #11)
• The implications for the patient if funding is not approved was not provided (Question #13)
  

An appeal must contain new information that was not available or provided at the time of the initial application.

Submit a letter of appeal to the program via fax along with supporting evidence. To avoid delays, CLEARLY provide the application number for the case you wish to appeal.

Appeal reviews require additional time to adjudicate and the program does not process appeals in the same timeframe as new applications.

The program could potentially deny appeals containing no new information, with no further comment. The program may place restrictions on the number of times an application can be appealed if the new information received still does not meet funding criteria and/or sufficient time has not passed to evolve the guidelines further to reflect new evidence and knowledge. We will indicate this on the decision letter. Guideline development is a dynamic process and the program will update the published guidelines as they evolve.

Instruct the patient to have their blood collected at a health authority outpatient laboratory or specimen collection centre. On the day of specimen collection, the patient must bring:

1. OOP/OOC Funding Approval letter indicating the test approved for funding and the address of the testing laboratory
   
2. B.C. laboratory requisition (for specimen collection)
3. Testing laboratory requisition and consent form, if appropriate

The specimen collection laboratory will collect the specimen(s) and send it to the testing laboratory. The patient must be aware and consent to their personal information and sample being sent to the testing laboratory outside the province.

The program approves funding through accredited vendor partners (PDF) that meet quality requirements.

Program staff will need to evaluate requests for testing at a previously unvetted laboratory, to ensure they meet criteria and that the program is able to set up third-party billing. We can only approve testing after we have successfully added the laboratory as an approved vendor.

The laboratory will send the test result to the practitioner who requested the test, as indicated on the B.C. laboratory requisition. Referring practitioners should contact patients to discuss the test result and care management.

The OOP program does not provide copies of any test result.

The program is responsible for paying the vendor laboratory that performed the approved test(s) for the amount indicated on the funding decision letter.

The letter includes instructions to the testing laboratory for billing.

Laboratories should not send bills for approved OOP/OOC laboratory and genetic tests to the patients, referring practitioners, or hospital laboratories responsible for specimen collection and shipment. The program has no ability to reimburse those entities.

In the event a specimen has been sent for testing without program approval, the shipping laboratory or requesting practitioner is responsible for covering the cost of the testing.