Out-of-Country Claim Forms

Policy Range 2

These forms are for group plan members with out-of-country healthcare coverage, with a group plan number that falls outside these number ranges:

• 56000 to 56300
• 56461 to 56599
• 250000 to 256499
• 330000 to 339999
• 340000 to 344999

If your group plan number does fall within the above numbers, use the out-of-country claim forms in the Policy Range 1 section instead.

If you are unsure of which forms you should use, have any questions or need help completing these forms call our Out-of-Country claims department at 1-800-957-9777.

Provincial third-party agreement forms

If your province of residence has a third-party agreement with Great-West, we may submit your out-of-country medical expenses to your provincial healthcare plan on your behalf. To do so, the provincial healthcare plans require specific authorization forms be completed, in full, by the person who incurred the medical expense.

Select your home province:

• Alberta
• British Columbia
• Manitoba
• New Brunswick
• Newfoundland and Labrador
• Northwest Territories
• Nova Scotia
• Nunavut
• Ontario
• Prince Edward Island
• Quebec
• Saskatchewan
• Yukon Territory

Alberta

Complete both claim forms in full and submit them to Great-West.

• Statement of Claim – Out-of-Country Expenses M5432(HO)
• Provincial third-party agreement form M5503

Alberta Health requires all claim documents be received within 12 months from the date the medical treatment was provided.

British Columbia

Complete all claim forms in full and submit them to Great-West.

• Statement of Claim – Out-of-Country Expenses M5432(HO)
• Provincial third-party agreement form M5502

The Medical Services Plan of British Columbia requires all claim documents be received within 90 days from the date of service, except for in-patient hospital services, which must be received within six months from the date the medical treatment was provided.

• Note: British Columbia residents are also required to provide a completed British Columbia Ministry of Health Out-of-Country Claim Form. This form is available at https://www.health.gov.bc.ca/exforms/msp/2814.pdf

Manitoba

Complete all claim forms in full and submit them to Great-West.

• Statement of Claim — Out-of-Country Expenses M5432(HO)
• Provincial Authorization and Assignment form M6824 BIL

The Medical Services Plan of Manitoba requires all claim documents be received within 6 months from the date the medical treatment was provided.

New Brunswick

Complete both claim forms in full and submit them to Great-West.

• Statement of Claim – Out-of-Country Expenses M5432(HO)
• Provincial third-party agreement form M5616 BIL

The New Brunswick Medicare Plan requires all claim documents be received within 12 months from the date the medical treatment was provided.

Newfoundland and Labrador

Complete all 3 forms in full and submit them to Great-West.

• Statement of Claim - Out-of-Country Expenses M5432(HO)
• Provincial third-party agreement form M5615 BIL
  Newfoundland and Labrador requires all claim documents be received within 12 months from the date the medical treatment was provided.

• Out of Province Claim form, available from the Government of Newfoundland and Labrador website at http://www.health.gov.nl.ca/health/mcp/forms/out_of_province_claim.pdf

Northwest Territories

• Great-West and The Northwest Territories do not currently have a third-party agreement. You must first submit your out-of-country medical expenses to the NWT Healthcare plan. Information about submitting expenses to the NWT Healthcare plan is available at www.hlthss.gov.nt.ca/english/services/health_care_plan/default.htm
• Once NWT has completed their assessment, submit a copy of your bills/receipts with their payment/denial statement, together with a completed Great-West Life Statement of Claim – Out-of-Country Expenses form M5432(MB) [PDF], to Great-West.

Nova Scotia

Complete both claim forms in full and submit them to Great-West.

• Statement of Claim — Out-of-County Expenses M5432(HO)
• Provincial third-party agreement form M5614 BIL

The Nova Scotia Medical Services Insurance Plan requires all claim documents be received within 6 months from the date the medical treatment was provided.

Nunavut

• Great-West and Nunavut do not currently have a third-party agreement. You must first submit your out-of-country medical expenses to the Nunavut Healthcare plan. For more information about submitting expenses to the Nunavut Healthcare plan, call 867-975-5700 and ask to speak with an out-of-country representative.
• Once they have completed their assessment, submit a copy of your bills/receipts with their payment/denial statement, together with a completed Great-West Life Statement of Claim — Out-of-Country Expenses form M5432(MB) [PDF], to Great-West.

Ontario

Complete both claim forms in full and submit them to Great-West.

• Statement of Claim — Out-of-Country Expenses M5432(HO)
• Provincial third-party agreement form M5500 BIL

The Ontario Health Insurance Plan (O.H.I.P.) requires all claim documents be received within 12 months from the date the medical treatment was provided.

Prince Edward Island

Complete both claim forms in full and submit them to Great-West.

• Statement of Claim — Out-of-Country Expenses M5432(HO)
• Provincial third-party agreement form M5613 BIL

The Health and Community Services Agency of Prince Edward Island requires all claim documents be received within 6 months from the date the medical treatment was provided.

Quebec

Complete all claim forms in full and submit them to Great-West.

• Statement of Claim — Out-of-Country Expenses M5432(HO)
• Provincial third-party agreement form M5501 BIL

• The Régie de l'assurance-maladie du Québec (RAMQ) requires all claim documents be received within 1 year from the date the medical treatment was provided, except for in-patient hospital services, which must be received within 3 years from the date the medical treatment was provided.
• Application for reimbursement form - Quebec residents are also required to provide a completed Application for reimbursement form, available at:
  http://www.ramq.gouv.qc.ca/en/formulaires/documents/1896.pdf

Saskatchewan

Complete all claim forms in full and submit them to Great-West.

• Statement of Claim — Out-of-Country Expenses M5432(HO)
• Provincial third-party agreement form M5611

Saskatchewan Health requires all claim documents be received within 6 months from the date the medical treatment was provided.

Yukon Territory

• Great-West and the Yukon Territory do not currently have a third-party agreement. You must first submit your out-of-country medical expenses to the YT Healthcare plan. For more information, call 867-667-5209 and ask to speak with an out-of-country representative.
• Once YT has completed their assessment, submit a copy of your bills/receipts with their payment/denial statement, together with a completed Great-West Life Statement of Claim — Out-of-Country Expenses form M5432(MB) [PDF], to Great-West.