How can you find out if your insurance covers a specific procedure?

Whether you are covered by the Alberta Health Care Insurance Plan (AHCIP) or have group/private coverage (Alberta Blue Cross, Sun Life, Manulife, Canada Life, etc.), checking your coverage before treatment will help you avoid unexpected costs. Below is a step-by-step guide for various types of medical, dental, and pharmaceutical procedures.

1. Checking coverage through AHCIP

1. Open the “What is covered” section on the Alberta government website and find your type of service. This section lists services that are fully covered, partially covered, and not covered.
2. Download the Schedule of Medical Benefits — the specialty section contains codes and descriptions of procedures marked as insured or non-insured.
3. If you don't have enough information, call AHCIP (780-427-1432) and ask for:

• the code/description of the procedure;
• whether prior approval is required.

4. Healthcare providers can check a patient's status and eligibility for services in the Alberta Netcare Person Directory — after authorization, the “Eligibility” line and its expiration date will be displayed.

2. Group or private health insurance

2.1. Online account and mobile app

1. Log in to your Member Portal (Alberta Blue Cross “Benefits,” Sun Life “Coverage search,” Manulife Group Benefits, Canada Life “My Canada Life at Work”).
2. Select “Coverage / Benefits” and enter:

• the name of the procedure, CPT/ADA code, or DIN code of the medication;

• the name of the provider (if requested by the system).

3. Check:

• the reimbursement percentage;
• the balance of your annual maximum;
• whether prior authorization / predetermination is required.

2.2. Written documentation

• Benefit Booklet / Plan Summary — find the required procedure in the “Covered Services,” “Exclusions,” and “Drug Formulary” sections.
• For medications, check the formulary (drug list); Manulife medications, for example, may require prior approval.

2.3. Contacting customer support

When calling the company, have the following information ready:

1. Policy number and group number.
2. Code or detailed description of the procedure.
3. Questions:

• Is the procedure covered?

• What is the copayment/deductible?

• Is a referral or pre-authorization required?

• How long will the decision be valid?

2.4. Predetermination / prior authorization

Without approval, the insurer may refuse to pay even after the procedure has been performed.

3. Verification with the service provider

1. Ask the clinic to send an electronic request to your insurer (in dentistry, this is instant).
2. Request a CDT/CDA estimate for dental services or a CMS-1500/UB-04 estimate for medical services, which will include codes and rates.
3. Compare the fees with the Alberta Blue Cross Dental Schedule or ADA Fee Guide to see how much of the cost may be your responsibility.

4. If the procedure is not covered

1. Alternative treatment options: discuss less expensive methods that are usually covered by your plan with your doctor.
2. Appeal / Exception: file an appeal, attaching a letter from your doctor stating the medical necessity. Many plans have a 30–45 day review process.
3. Health Spending Account or Wellness Account (if provided by your employer) can be used for the uncovered portion.
4. Clinic financing: Dentists and private surgeons often allow payment in installments.

5. Useful contacts in Calgary

6. Quick checklist before the procedure

1. Check your coverage in your online account or booklet.
2. Obtain predetermination/prior authorization if the amount is large or special approval is required.
3. Agree on the final estimate with the clinic, taking into account the difference from the insurer's rate.
4. Keep all written confirmation of coverage — you will need it when filing a claim.

Conclusion

To make sure your insurance will cover a specific procedure in Calgary, use a three-step verification process:

1. official coverage lists (AHCIP or benefit booklet);
2. insurer tools (online account, predetermination, prior authorization);
3. confirmation from the service provider.

Following these steps ensures transparency of costs, minimizes claim denials, and helps you plan your treatment budget without unpleasant surprises.