Custom Foot Orthotics Claiming Checklist
for Pacific Blue Cross Members
Ensure you provide the following when submitting a claim for custom-made foot orthotics:
ü A completed Blue Cross claim form
ü An original receipt indicating that payment has been made in full (A copy of the receipt is
acceptable if the primary carrier’s explanation of benefits is attached.)
ü A copy of the current prescription outlining the medical diagnosis from a physician, podiatrist,
physiotherapist or chiropractor
ü A copy of your biomechanical assessment, which must be performed in person by your provider
(A biomechanical assessment is an examination of the lower limb bone alignment. It involves looking at the patient’s
movement and walking patterns, interaction of the foot with the rest of the body and shoes to determine wear patterns to
assist in recovery of a recurrent injury or prevent further injury.)
ü Written confirmation from the person who made the product indicating that the orthotic was
fabricated from raw material, using a 3-D volumetric model of the patient’s foot, using one of the
following casting techniques:
Plaster of paris slipper cast
Semi-weight bearing foam casting box
3-D contact digitizing (e.g. pin array system)
3-D laser imaging scanning
If this information is not included on your receipt, your provider can use the form below.
This will help us accurately adjudicate your claim and provide timely reimbursement.
Note: Not all extended health care plans cover foot orthotics. You can verify coverage eligibility by
referring to your plan brochure, logging onto CARESnet® (our member self-service website) or by
calling our Customer Service department at 604 419-2600 or 1 888 275-4672. Please submit claims and
supporting materials directly to: Pacific Blue Cross, PO Box 7000, Vancouver BC V6B 4E1.
Thank you for your cooperation.
and Casting Form
To be completed and signed by the person who made the product.
Please detach and submit with your claim if no other writt