Benefit Grid for Pre-departure Medical Services (PDMS) April 1, 2017
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1 Benefit Grid for Pre-departure Medical Services (PDMS) April 1, 2017 Corresponding 501, 703, 707, 712, , 703, , , 703, 707, 712 IME fees (combinations) IME + HIV + Syphilis + Chest X-ray + Urinalysis (>=15 years) IME+ Chest X-ray + Urinalysis (11-14 years) IME + Urinalysis (5-10 years) IME + HIV + Syphilis + Urinalysis (Pregnant) HXUO 01-Apr-17 1/8 CM See NOTE XUO 01-Apr-17 1/8 CM See NOTE EUO 01-Apr-17 1/8 CM See NOTE HSUO 01-Apr-17 1/8 CM See NOTE 1 IME fees (Individual Services and Tests) 501 IME (exam only) CIO 01-Apr-17 1/8 CM See NOTE 1 502, 503, 504, 508, 509, 510 Chest X-Ray CXO 01-Apr Lab Exam (URINALYSIS) LO 01-Apr Venereal Disease Research Lab (SYPHILIS TEST) VDRO 01-Apr HIV Lab test (HIV) HLTO 01-Apr Syphilis Confirmation Tests SCTO 01-Apr HIV Confirmation Tests HIVO 01-Apr Post Test Counselling for HIV Sputum Culture and Smear (TB) Hepatitis B-surface Antigen PHO 01-Apr-17 Yes SPO 01-Apr HBO 01-Apr Creatinine, serum CRO 01-Apr HCV Serology (Anti HCV IgM/IgG) Furtherance HCVO 01-Apr-17 See NOTES 1, 10 & 21 See NOTES 1 & 10 See NOTES 1, 8 & 10 See NOTES 1 & 10 See NOTE 2 See NOTE 9 1/8CM See NOTES 6 & FPPO 01-Apr-17 RMO See NOTE 24 Page 1 Version April 2017
2 Corresponding Furtherance MD / specialist (Public health concerns only TB or Syphilis) or HIV specialist Furtherance MD / Psychiatrist (Public safety concerns only) FPSO 01-Apr FO 01-Apr-17 or RMO or RMO See NOTE 25 See NOTE 4 Treatment of TB and Syphilis 711 Block fee: Treatment of Syphilis SYO 01-Apr-17 Yes See NOTES 3 & 11 Block fee: Treatment of Hospital Services In-patient Treatment of Hospital Services Out-patient Treatment of Services Diagnostic Tests (Laboratory) Treatment of Diagnostic Tests (X-ray) Pharmaceuticals TBO 01-Apr-17 Yes HTBO 01-Apr-17 Yes OTBO 01-Apr-17 Yes DTBO 01-Apr-17 Yes LTBO 01-Apr-17 Yes XTBO 01-Apr-17 Yes PTBO 01-Apr-17 Yes See NOTES 5, 12 & 13 Vaccinations (IOM sites only) Measles Mumps Rubella Vaccine (MMR) MVO 01-Apr-17 2 LT See NOTES 14 & 22 DTaP / DTP Diphtheria- Tetanus-Pertussis (a = TVO 01-Apr-17 2 LT See NOTES 15 & 22 acellular) Inactivated Polio Virus (IPV) / Oral Polio (OPV) PVO 01-Apr-17 2 LT See NOTES 16 & 22 Hepatitis B HEPO 01-Apr-17 2 LT See NOTES 20 & 22 Haemophilus influenza type B (Hib) Tdap/TD Low dose Tetanus-diphtheriaacellular pertussis / Tetanus-diphtheria FLUO 01-Apr-17 2 LT See NOTE LTVO 01-Apr-17 1 LT See NOTES 17 & 22 Page 2 Version April 2017
3 Corresponding Rotavirus RTVO 01-Apr-17 2 LT See NOTE 22 Pertussis, Polio, Hib, Hepatitis B Pertussis, Hib, Hepatitis B Pertussis, Polio, Hib DPPO 01-Apr-17 2 LT See NOTE DTHO 01-Apr-17 2 LT See NOTE DTPO 01-Apr-17 2 LT See NOTE 22 Outbreak Response Management Outbreak Response Management Fee Medical Support in Transit Medical Escort and 610 Support Fee MGTO 01-Apr-17 Yes See NOTE SRTO 01-Apr-17 Yes Yes 1 LT See NOTES 18 & 19 * 1/CY= One per Calendar Year, 1/LT= One per Life Time, 1/8 CM = One per 8 Calendar Months A special authorization/approval is required prior to providing a client with eligible benefits/services. NOTES: NOTE 1 - Cannot be billed with another individual or combination IME that includes the same service/benefit. NOTE 2 - Syphilis confirmation test may include the following: TP-PA, FTA-Abs, INNO-LIA, RPR automated enzyme immunoassays (EIAs) or immunochermoluminescence tests, treponemal and nontreponemal tests. NOTE 3 - Coverage includes investigation, management and treatment of clients with a positive syphilis test according to the Canadian protocol and/or referral to an infectious disease specialist (if required). NOTE 4 - Coverage includes referral and assessments at a mental health centre/hospital or by a specialist (psychiatrist), review of history, written reports, recommendations and any additional follow-up visits. Referral from a or RMO Medical Officer is required. NOTE 5 - Coverage includes referral to a TB centre/hospital or a specialist for TB investigations and/or treatment including Directly Observed Treatment (DOT). Services covered: physician services; prescription medications and over the counter (OTC) products; diagnostic tests including for latent TB (IGRA); X-ray investigations; out-patient and in-patient hospital treatment of Active TB; OR prophylactic treatment of LTB or close contacts. Page 3 Version April 2017
4 NOTE: Coverage does not include treatment of MDR TB or XDR TB cases. NOTE 6 - Must include diagnosis of HIV / AIDS. NOTE 7 - The cost and services must be approved by IRCC. Services may include: Diagnostic testing (rapid and serologic); Post exposure prophylaxis (vaccines and drug therapy); Pre-departure health screening and personnel costs during outbreak management; or nurse visits to conduct a fitness to fly check, immediately prior to travel to Canada, to identify any delayed recovery from the outbreak disease that would make travel unsafe for the client or threaten public health. NOTE: In exceptional cases, where outbreaks warrant immediate delivery of services, the request may be reviewed post factum. NOTE 8 - Coverage includes polymerase chain reaction (PCR), nucleic acid sequence-based amplification (NASBA) or by Branched DNA (bdna) methods. NOTE 9 - HIV confirmation test cost may include: Western Blot, Immunoblot, Radioimmunoprecipitation or Immunofluorescence. NOTE 10 - Cannot be billed with another IFHP fee that includes the same benefit. NOTE 11 - Claims must include diagnosis of Syphilis. NOTE 12 - Claims must include diagnosis of Tuberculosis. NOTE 13 - The treatment may be reviewed by a Medical Officer (IRCC RMO). NOTE 14 - Vaccination dosage: 2 doses when greater than 1 year old or born on or after NOTE 15 - Vaccination dosage: 2 doses at least one month apart if 6 weeks to <7 years of age. NOTE 16 - Vaccination dosage: 2 doses if between 6 weeks old and under 11 years old. NOTE 17 - Vaccination dosage: 1 dose if > 7 years of age. NOTE 18 - Services must be approved by IRCC. NOTE 19 - The cost may include: The cost of travel by the most direct route at the most economical rate available for medical escort (nurse, MD) or a non-medical support (i.e. in cases where only personal care/support is required during the travel). The cost may include one way or round trip airfare; The cost of least expensive assistive devices, oxygen and surgical supplies, pharmaceuticals (recommended to have at least a 30 day supply of prescription meds);the eligible cost may also include: charges for any transportation tax (for example, toll or airport tax); Additional service fee approved by IRCC; Transportation cost for a medical escort from the refugee s place of residence in a rural community or camp, to a city from which the refugee may board a flight that would commence their trip to Canada, which may include meals en route, overnight accommodation, ground transportation and incidental expenses; The cost of overnight accommodation in Canada and meal allowances; Additional medical examinations to identify fitness for travel (i.e., pulmonologist's or cardiologist's reports etc.) Note: cost of treatment to stabilize patients for the travel is not covered. NOTE 20 - For clients with risk factors HBsAg testing must be administered prior to vaccination. Page 4 Version April 2017
5 NOTE 21 - The cost may include chest X-ray (PA, Lateral, Lordotic) images and examination reports. NOTE 22 - Coverage includes: the cost of procurement, transportation, storage, preparation and administration of vaccines, including counselling and documentation of the patient s vaccine administration information and pregnancy test where applicable. NOTE 23 - Can only be billed for HIV Positive Tests. NOTE 24 - Coverage includes: the cost of the first and subsequent visits, diagnostic tests, interim, final treatment reports. NOTE 25 - Coverage includes: the cost of the first and subsequent visits, diagnostic tests, interim, final treatment reports. Page 5 Version April 2017
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