Provider
A provider is a licensed healthcare professional, facility, or service organization that delivers medical, dental, vision, or paramedical care to patients. In the context of insurance, a provider is any individual or entity authorized to perform covered services and submit claims for reimbursement to an insurer. Providers include physicians, dentists, pharmacists, physiotherapists, chiropractors, optometrists, hospitals, and clinics.
How It Works
A provider can be any person or organization that delivers health care goods or services to a patient, which covers health care professionals as well as trainees, students, and others acting at the direction of a provider. The label is often equated with a regulated health professional, though it is not exactly the same, since a regulated professional works within a scope of practice controlled by legislated regulatory bodies. Under the Canada Health Act, a health care practitioner is a person lawfully entitled under provincial law to provide health services where the services are given, and a dentist is a person lawfully entitled to practise dentistry where the practice is carried on. In Canada, public health insurance must cover medically necessary hospital, physician, and certain surgical-dental services delivered by recognized providers, while services such as non-surgical dental and prescription drugs fall to private plans or provincial programs at provincial discretion.
Example:
Suppose you see a physiotherapist after a sports injury in Canada, and that clinic is listed as an approved provider under your extended health plan. Because the clinic is approved, it can bill your insurer directly, and you only pay the remaining balance your plan does not cover.
What to Watch For:
Plans often distinguish between in-network providers, who have agreed to direct billing arrangements and negotiated rates with the insurer, and out-of-network providers, who may charge higher fees and require you to pay upfront and submit a claim for reimbursement. Some plans also require that services be delivered by specific professionals, such as a registered massage therapist rather than an unregistered practitioner, before the cost will qualify for reimbursement. Check these requirements before booking care so your provider is recognized and your claim goes through.
