What Is Predetermination?

SPECIAL REPORT: What Is Predetermination and Do You Need One?

Intro: Predetermination Isn’t a Barrier – It’s a Benefit

If you\’ve ever been told that your massage, physiotherapy, or chiropractic care “might not be covered without predetermination,” you’re not alone — and you’re not wrong to feel confused.

Let’s get clear on this:

Predetermination is not about jumping through hoops. It’s about knowing before you go — and avoiding claim surprises that could cost you hundreds.

In this in-depth report, we’ll break down what predetermination means in the Canadian insurance system, when you need one, how to get it, and how to use it to your advantage as a patient and provider.

🧾 What Is Predetermination? (Plain English)

A predetermination is a formal request sent to your insurance company before you receive treatment, asking:

\”Will this service be covered?\”
\”How much will be reimbursed?\”
\”Do I need a referral or doctor’s note first?\”

The insurer then reviews the request and sends back a response confirming:

✅ What they will pay
✅ What you need to provide
❌ Any conditions or limitations

It’s essentially pre-approval, giving you a financial green light (or yellow flag) before you commit to a treatment plan.

🏥 When Do You Need a Predetermination?

Most basic claims don’t need one. But you should or must submit one if:

Your treatment will cost more than $300–$500
You\’re booking multiple sessions in advance (e.g., a 10-visit physio plan)
You’ve already made several claims this year
Your insurance plan or provider requires a doctor’s referral
You\’re uncertain about whether a service is eligible (e.g., cupping or acupuncture add-ons)

Insider tip: Some providers (like Manulife or Desjardins) require predetermination after your benefit maximum is nearly used, especially for extended care.

📋 How to Submit a Predetermination Step-by-Step

Most clinics will help you submit it. Here\’s the typical process:

✅ Assessment Visit with your RMT, physiotherapist, or chiropractor
🧾 The clinic fills out the predetermination request form
📬 You (or the clinic) submits it to your insurer by email, online portal, or mail
⏳ Wait 5–10 business days for a written response

Once approved, your insurer sends back a letter or notice outlining:

The service(s) approved
The coverage amount per session
Any conditions or exclusions

🔁 Some insurers give partial approval — for example, 6 of 10 sessions. You may need to reapply for additional coverage.

⚠️ What Happens If You Don’t Submit One?

If you skip this step when required:

Your claim might be denied in full
You may have to pay 100% out of pocket
It may create a red flag in your insurance profile for “non-compliant claims”
Clinics may be unable to direct bill until it\’s sorted

Bottom line: If your therapist or clinic advises predetermination, take it seriously — it protects both you and your provider.

💡 How Predetermination Protects Patients

Many think it’s an unnecessary delay. But in truth, it’s a powerful tool:

Avoid surprise bills
Get written proof of coverage
Clarify coverage BEFORE treatment
Easier budgeting (especially for co-pays)
Prevents retroactive denials

It also creates a paper trail showing your insurer knew exactly what treatment was proposed — helping in appeals if needed.

🧠 What Types of Services Usually Require It?

Service Type	Predetermination Needed?
Regular 1x massage	❌ Rarely
RMT 5-pack treatment	✅ Often
Post-accident physio	✅ Almost always
Advanced chiropractic plan	✅ Yes
Acupuncture or cupping add-ons	✅ Yes (depends on insurer)
Multi-practitioner care plan	✅ Required for complex plans

Some government-linked plans (e.g. Medavie Blue Cross for Veterans or RCMP) always require it before services begin.

✅ What You Should Ask Your Clinic Before Booking

“Do I need a doctor’s note for this claim?”
“Should I request a predetermination before we start?”
“Can you help me submit it?”
“How long will the insurer take to respond?”

At northtormt.com/, all clinics in our directory understand the process and can walk you through it — or submit on your behalf.💬 Ruby, our virtual insurance assistant, can even send reminders and help track your insurer response at insurance.rmtclinic.net.

🔄 What to Do After Approval Comes In

Once your predetermination is approved:

✅ Proceed with care as planned
📑 Keep your approval notice on file
🧾 Ensure your receipts match exactly what was approved
💬 Resubmit or call insurer if anything changes (e.g. therapist changes)

✅ Action Checklist

📑 Download your insurer’s predetermination form
📞 Call your clinic or use northtormt.com/ to book an assessment
📥 Submit form + referral if needed
📬 Wait for written approval
💬 Ask Ruby to track your claim step-by-step

✍️ About the Author

Henry Tse is the founder of RMT Clinic Network Organization. With 35+ years in entrepreneurship and healthcare advocacy, he helps Canadians understand — and maximize — their para-medical insurance benefits. Henry believes in clear answers, smart strategy, and helping patients unlock every dollar of coverage they deserve.