What the KNEEB-110 is for
Green Shield uses the KNEEB-110 to decide, before the patient buys a custom brace, how much of the cost the plan will cover. The form asks you to say medically why a custom brace is necessary instead of a standard one, so your justification carries as much weight as the diagnosis. Green Shield replies to the patient with a letter outlining its liability, and the form says that decision isn’t meant to interfere with the treatment you recommend.
Green Shield has a separate form, the MED-130, for prosthetic appliances and durable medical equipment.
Who completes it
The patient or guardian completes Section I in full: name, date of birth, age, address, Green Shield ID number, phone, email, and any other group insurance that may cover the brace. The treating physician completes Section II and signs it with their printed name and phone number.
The usual route is the orthotist or brace fitter giving the patient the form with a quote, the patient filling in Section I, and the form landing at your clinic for Section II. In Medulla, you send Section I to the patient over a secure link. They fill it in from their phone, and their answers land on the PDF you complete Section II on, so Green Shield gets one complete form with the ID number already on it.
How to fill in Section II
The prescription
Name the type of brace, mark left, right, or bilateral, and enter the estimated cost. Add the specifications when you have them, which usually come from the orthotist’s quote.
Condition, duration, and diagnosis
Mark whether the condition is acute or chronic, and how long the patient will need the brace, in weeks, months, years, or lifetime. The form asks you to be specific about the diagnosis, so give the laterality and the structure involved, such as a complete ACL tear of the right knee or medial compartment osteoarthritis, rather than “knee pain”.
Past treatment and joint space
Mark the treatment already tried: physiotherapy with the number of treatments, surgery, medications, and x-rays. For a brace for arthritis, record the degree of joint space loss, or mark not applicable.
Why custom and not standard
This is the question the request turns on. Explain the medical reason a standard brace isn’t enough: limb shape or size that a stock brace won’t fit, instability a stock brace failed to control, skin breakdown, or a previous off-the-shelf brace that didn’t work.
Cost, replacement, and other funding
Say whether the brace was shown to the patient and the costs provided. If the brace is a replacement, give the reason. Say whether the patient applied for government funding, and if not, why. Answer whether the brace is needed because of a work-related injury, a motor vehicle accident, or for sports only.
Common reasons it’s delayed
- Section I incomplete, often missing the Green Shield ID or other coverage.
- No reason given for a custom brace over a standard one.
- A vague diagnosis with no side or structure.
- No estimated cost or brace type.
- The brace bought before pre-approval was requested.
- An unsigned Section II.
Submitting and who pays
The patient sends the completed form for prior approval to Green Shield’s EHS Department at P.O. Box 1623, Windsor, Ontario, or by email to its medical authorization address or by fax, all printed on the form. Claims must be submitted within 12 months of the date of service unless the plan says otherwise. Any cost of completing the form is the patient’s, so bill the patient.