What the MED-130 is for
Green Shield uses the MED-130 to decide, before the patient buys a prosthetic appliance or durable medical equipment, what the plan will pay. The form covers a wide range of items, and it has extra questions for three of them: PAP devices, hospital beds, and viscosupplementation. Green Shield replies to the patient with a letter outlining its liability, and the form warns that not asking for pre-approval may result in a denied claim.
Custom braces have their own form, the KNEEB-110. Provincial assistive device programs, where they apply, are separate applications, and the MED-130 asks whether the patient has applied for government funding.
Who completes it
The patient or guardian completes Section I in full: name, date of birth, address, Green Shield plan member ID, phone, email, and any other group coverage that may include the item. The physician completes Section II and signs it with their printed name and phone number.
Patients usually get the MED-130 from the equipment vendor along with a quote, fill in Section I, and leave the form at the clinic for you to complete Section II by hand. In Medulla, you send Section I to the patient over a secure link before the visit. They fill it in on the form from any device, and their answers land on the PDF you complete Section II on, so the plan member ID and other coverage arrive already filled in.
How to fill in Section II
The prescription
List each prosthetic appliance or piece of equipment on its own line, up to five, with specifications where you have them and an estimated cost for each. The first line is required. Copy the item names from the vendor’s quote so they match the invoice Green Shield sees later.
Condition, duration, and diagnosis
Mark the patient’s condition as acute, chronic, or palliative, and the duration of need in weeks, months, years, or lifetime. Give a specific diagnosis. For a palliative patient, a hospital bed or commode needs the underlying diagnosis, not just “end of life”.
Device-specific questions
For a PAP device, give the apnea-hypopnea index from the sleep study. For a hospital bed, give the hours or percentage of time the patient spends in bed. For viscosupplementation, mark the left or right knee. Leave the questions that don’t apply blank.
Why a standard item isn’t enough
The form asks why a standard item isn’t sufficient and a custom one is required. Answer it whenever you prescribe anything above the basic model, with the clinical reason: fit, skin integrity, weight, or a standard device that failed. Leave it blank only when you’re prescribing the standard item.
Replacement, funding, and cause
Say whether the item replaces an earlier one, and why. Say whether the patient applied for government funding, and if not, the reason, or mark not applicable. Answer whether the item is needed because of a work-related injury, a motor vehicle accident, or for sports only.
Common reasons it’s delayed
- No AHI given for a PAP device.
- No time in bed given for a hospital bed.
- Items listed with no estimated cost.
- A custom or upgraded item with no reason a standard one won’t do.
- The government funding question left blank.
- Section I missing the plan member ID or other coverage.
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 the medical authorization address printed on the form. Claims must be submitted within 12 months of the date of service unless the plan documents say otherwise. Any cost of completing the form is the patient’s, so bill the patient directly.