Guide to mental health counselling benefits for First Nations and Inuit
Effective date: October 19, 2023
Express Scripts Canada provides claims processing services for the NIHB program mental health counselling benefit for eligible First Nations and Inuit. Providers are encouraged to enrol to be able to send their claims directly to Express Scripts Canada so that clients do not pay fees at the point of service.
The NIHB mental health counselling benefit is not an emergency service. If you or someone you know is in immediate danger, call 9-1-1 or the number for emergency services in your community.
If you're experiencing emotional distress and want to talk, call the First Nations and Inuit Hope for Wellness Help Line at 1-855-242-3310 or the online chat at hopeforwellness.ca. It's toll-free and open 24 hours a day, 7 days a week.
Indian Residential Schools Resolution Health Support Program
The National Indian Residential School Crisis Line provides 24-hour crisis support to former Indian Residential School students and their families toll-free at 1-866-925-4419. Counselling, as well as cultural and emotional support is also available through the Indian Residential Schools Resolution Health Support Program for eligible former students and their families.
- 1.0 Introduction
- 2.0 Provider eligibility, enrolment and payments
- 3.0 Service eligibility
- 3.1 Client eligibility
- 3.2 Client roles and responsibilities
- 3.3 Eligible services: Coverage and frequency guidelines
- 3.4 Types of eligible mental health counselling
- 3.5 Exceptions
- 3.6 Exclusions
- 3.7 Prior approval (PA) process
- 3.8 Claim submission
- 4.0 Appeal process
- 5.0 Medical transportation
- 6.0 Mental health counselling benefits resources
- 7.0 Appendices
1.1 Purpose of the guide
This guide outlines the terms and conditions, criteria, guidelines and policies for the NIHB program's professional mental health counselling benefit, including:
- client eligibility
- provider eligibility
- benefit coverage
- prior approval process
- claims submission process
Administrative information for NIHB providers on how to submit prior approval requests and make claims can be found in the Mental Health Counselling Claims Submission Kit, available on the Express Scripts Canada NIHB provider and client website.
For more information, clients and providers may contact the NIHB regional office.
A note about traditional healing…
Indigenous Services Canada has entered into separate agreements with some First Nations and Inuit communities and organizations in each region to assist with the delivery of traditional healing services in support of mental health counselling. For more information regarding these services, please contact your local community for information on Elder and Traditional Healer services they may offer. Note that not all communities may offer this service.
1.2 NIHB program - overview
Indigenous Services Canada's (ISC) Non-Insured Health Benefits program is a national program that provides eligible First Nations and Inuit clients, residing in Canada, with coverage for a range of medically necessary health benefits when these benefits are not otherwise covered through private or provincial or territorial health insurance plans or social programs.
NIHB program benefits include prescription drugs and over-the-counter medications, dental and vision care, medical supplies and equipment, mental health counselling, and transportation to access medically required health services that are not available on the reserve or in the community of residence.
For some First Nations and Inuit clients, mental health counselling benefits coverage is managed and delivered by a First Nations or Inuit community, organization, regional health authority or other government (for additional information, see Appendix D: Self-government agreements and other community-managed benefit coverage). Please note that these requests are not processed by Express Scripts Canada or the NIHB program. Clients and service providers can contact the responsible community health services or regional health authority for information about their process for accessing benefits.
1.3 NIHB mental health counselling benefit - overview
The mental health counselling benefit is based on supporting a planned and scheduled therapeutic approach to mental health intervention and operates as part of a continuum of mental wellness programs provided by Indigenous Services Canada, which complement other mental wellness services that are provided in/by communities, and by/through provinces and territories. Providers are expected to make themselves aware of the mental wellness services available in the community, and locally from the province or territory and ensure the client is aware of the availability of such services. An overview of other Indigenous Services Canada's mental health counselling programming can be found in section 6.2 Mental health counselling programming and at Indigenous mental health webpage.
Clients can contact their NIHB regional office for assistance in locating an NIHB-enrolled mental health counselling provider in their area. Providers who are enrolled with the NIHB program can bill the program directly for services provided to eligible clients. As services are available on the schedule of the professional, clients are encouraged to contact the provider to make an appointment for counselling services and to confirm the provider will bill the program directly for services provided to the client.
The provision of this benefit is part of Indigenous Services Canada's commitment to work towards the development of a coordinated and comprehensive approach to mental health and addiction programming. Mental health counselling coverage is offered in a way that:
- recognizes NIHB mental health counselling benefit as a component of a mental wellness continuum that includes other Indigenous Services Canada, community-based and provincial or territorial mental health programming and services
- supports culturally competent mental health counselling
2.0 Provider eligibility, enrolment and payments
2.1 Provider eligibility
Health professional regulation and licensing is a provincial and territorial jurisdiction. To be eligible under the NIHB program, a provider must meet ALL of the following conditions:
- registered in good standing by a Provincial/Territorial legislated regulatory body responsible for the licensing of mental health counselling professionals in the province or territory in which the client receives services
- practising in accordance with the Provincial/Territorial legislation governing the licensing of such professionals
- where a clinical designation exists (example, Clinical Social Worker), that designation is required
- eligible for independent, unsupervised practice
Based on these requirements, with the exception of a very limited number of providers who meet the criteria outlined in Appendix A: Eligible provider types by province and territory, only the types of regulated professionals listed are eligible to enrol under the NIHB program. Membership in a professional association is not equivalent to being licensed by a provincial or territorial regulatory body.
A provider's disciplinary history may be considered as part of NIHB's review of the billing agreement application.
Providers must be operating physically in Canada in order to be eligible as an NIHB mental health counselling provider. Regarding providers of interprovincial mental health telecounselling services in exceptional circumstances, please refer to Appendix C: Interprovincial mental health telecounselling.
2.2 Provider enrolment process
Providers wishing to deliver services reimbursed by NIHB must complete a Mental Health Counselling Billing Agreement found in the Mental Health Counselling Professional Provider Enrolment Package, available on the Express Scripts Canada NIHB provider and client website, and submit it to Express Scripts Canada.
See Appendix D: Self-government and other community-managed benefit coverage for clients whose NIHB coverage is managed through an alternate arrangement such as self-government. Express Scripts Canada cannot process claims for such clients.
To avoid the appearance or existence of a conflict of interest, providers must disclose any work that they do with other mental health/wellness programs or organizations that provide services to members of First Nations or Inuit communities. A provider offering professional services to a First Nation or Inuit community organization, whether as an employee or an independent contractor, shall disclose in writing to the NIHB regional office within 10 days of starting such arrangements. Failing to disclose this information may lead to the suspension or termination of the aforementioned agreement.
For greater clarity, should the provider offer employment or professional services to a community organization funded through a contribution agreement with Indigenous Services Canada, the provider may not refer the clients receiving services in the community to their independent/private practice and submit any claims under the NIHB Provider number issued by Express Scripts Canada.
2.3 Provider roles and responsibilities
Before initiating counselling, providers must confirm that the client and any services they propose to provide to the client are eligible for coverage, as ineligible services will not be reimbursed. Regarding exceptional circumstances, where the client and the provider are not physically located in the same province, refer to Appendix C: Interprovincial mental health telecounselling. By submitting a payment request to Express Scripts Canada, a provider indicates understanding and acceptance of the terms and conditions for receiving payment for services.
- be aware of the current continuum of mental wellness services available to clients in their community, and locally from the province or territory
- confirm that the client is eligible for NIHB
- submit claims for services they have provided directly. Each eligible provider must enroll and submit claims under their distinct number. Distinct provider numbers are not interchangeable. No claims may be submitted for services by ineligible providers
- follow requirements for prior approval to ensure services are eligible for coverage (if prior approval is not obtained before continuing counselling beyond the initial assessment, there remains a risk to the provider as ineligible services will not be paid)
- ensure that the client understands the coverage that is available
- complete a client assessment and discuss the recommended number of counselling hours and frequency of counselling with the client
- complete a treatment plan to be kept on the client's file. A copy of the treatment plan may be requested as part of the exceptions process outlined in section 3.5 Exceptions
- keep all client records (including date, location, and start/end time)
- ensure that they do not knowingly submit a claim for payment for services that are funded by or will be paid by another plan or program (where there is coordination of benefits, this must be clearly marked)
- comply with professional regulatory body requirements for security, police record checks, and client file management
- maintain active licensure and notify the NIHB regional office and Express Scripts Canada (1-888-511-4666) immediately upon a change of standing with their regulatory body (this includes, but is not limited to, the introduction of a remediation plan or any restrictions in practice put in place. See section 2.1 Provider eligibility)
- bill at their usual and customary rate, but no higher than the current Mental Health Counselling Regional Fee Grids, available on the Express Scripts Canada NIHB provider and client website
- avoid conflicts of interest
As part of the treatment plan, the provider is encouraged to link the client to community-based mental health counselling services or other culturally appropriate services, where available.
As part of their ongoing professional development, providers are encouraged to continue to enhance their knowledge of First Nations and Inuit cultures. This can include opportunities provided by their professional associations, through First Nations or Inuit communities or organizations, or other related training.
The Mental Health Counselling Services Information Form in the Mental Health Counselling Professional Provider Enrolment Package, available on the Express Scripts Canada NIHB provider and client website, provides an opportunity for providers to indicate their areas of expertise or specialization, and to say that they have experience in supporting First Nations and Inuit (cultural competence). Please note, this information is not reviewed by the NIHB program for completeness or accuracy. To be sure to have the most up-to-date information in choosing a provider who meets their needs, clients are encouraged to contact the provider's office directly.
Clients seeking a list of providers with particular areas of expertise or specialization can contact their regional office.
Providers are encouraged to update their record by contacting the NIHB Call Centre at Express Scripts Canada to maintain an up-to-date record of their areas of expertise or specialization. Clients may contact the programs to request the names and contact information of providers with particular areas of expertise or specialization.
Mental health counselling providers must follow applicable privacy legislation, regulations and professional regulatory body requirements applicable to maintaining their records. Client files are in the control of the provider and not Indigenous Services Canada.
2.4 Provider Claim Verification Program (PCVP)
As part of the NIHB program's risk management activities, Indigenous Services Canada has mandated its claims processor to maintain a set of pre-payment and post-payment processes, including claim verification activities.
This function incorporates the review of claims against records to confirm compliance with the terms and conditions of the NIHB program. If under any circumstances it is found that a provider has inappropriately billed the program, claim payments will be recovered; either by direct payment from the provider or withheld from future provider claim statements.
Detailed information about the Provider Claim Verification Program and procedures can be found in section 6 of the Mental Health Counselling Claims Submission Kit available on the Express Scripts Canada NIHB provider and client website.
2.5 Privacy statement
Indigenous Services Canada's NIHB program has the responsibility to protect personal information under its control in accordance with the Privacy Act and its related Treasury Board policy and directives, and is responsible for ensuring that the personal information collected is limited to that which is necessary to administer the program.
For more information, please contact Indigenous Services Canada's Access to Information and Privacy (ATIP) Coordinator at 819-997-8277 or email@example.com. You also have the right to file a complaint with the Privacy Commissioner of Canada if you think your personal information has been handled improperly.
3.0 Service eligibility
3.1 Client eligibility
The provider must verify that the individual is eligible for benefits under Indigenous Services Canada's NIHB program. Providers are asked to identify any other benefit coverage available to the client, if applicable.
To be eligible, a client must be a resident of Canada, and one of the following:
- a First Nations individual who is registered according to the Indian Act (commonly referred to as a "Status Indian")
- an Inuk recognized by one of the Inuit land claim organizations as outlined in Inuit client eligibility for NIHB
- a child less than 2 years old, whose parent is an NIHB-eligible client
Refer to the NIHB program webpage Who is eligible for the NIHB program.
In order to confirm client eligibility prior to service provision, clients or providers may contact their local NIHB regional office.
Please note that NIHB coverage is provided for the individual eligible client only and is not family coverage. Services to eligible clients must be billed using each eligible client's individual identification number. Providers may not use a client's identification number to bill the NIHB program for services provided to dependants or individuals other than the individual client.
More detailed information about Client Identification and Eligibility is included in section 4 of the Mental Health Counselling Claims Submission Kit, available on the Express Scripts Canada NIHB provider and client website.
See Appendix D: Self-government and other community-managed benefit coverage for information on health benefit coverage provided by First Nations and Inuit governments and community-based organizations directly to their members.
3.2 Client roles and responsibilities
3.2.1. Finding a provider and accessing services
Enrolled mental health counselling providers are professionals who operate their own private practice(s) or are employed by private practice(s); they are not employees of the NIHB program. As such, the NIHB Regional office does not make appointments for or on behalf of clients nor assign providers to clients. Typically, providers operate by appointment, and individual clients are responsible for contacting the provider to make an appointment.
If a client requires assistance to locate a local, NIHB-enrolled mental health counselling provider, please contact the NIHB regional office for assistance. If medical transportation support may be required, please refer to section 5.0 Medical transportation.
When clients call a provider about booking an appointment, clients are encouraged to ask the provider if they will:
- bill the NIHB program directly for the cost of services provided
- charge the client any costs in addition to the amount the provider bills to the program
Clients will need to know their NIHB client identification number, and share this with the mental health counselling provider's office so their provider can seek the necessary approvals and bill the program for counselling services provided to the client.
Clients should be aware that only services delivered by an eligible provider (see section 2.0 Provider eligibility and Appendix A: Eligible providers by province and territory) are eligible for reimbursement. Before booking an appointment, clients are encouraged to call the NIHB regional office to confirm whether a provider is enrolled with NIHB and/or eligible to provide services that may be reimbursed.
Clients are not limited to enrolled providers only: if a client would like to work with an eligible counsellor (see section 2.1 Provider eligibility and Appendix A: Eligible providers by province and territory) who is not yet enrolled with Express Scripts Canada, the provider should apply for enrolment before counselling begins (if they do not do so, they will not be able to bill the program directly for services provided to the client). For clients who pay out of pocket for eligible services, see section 3.8.6 Client reimbursement.
Clients must first access any alternate health coverage that is available to them. They should also contact their local community organizations (health centre, friendship centre, or primary health care provider) and/or the NIHB regional office to determine what other community mental health counselling programs are available.
As outlined in Appendix D: Self-government and other community-managed benefit coverage, some clients receive coverage for mental health counselling benefits through their community, health authority, or other government. Such claims cannot be paid through Express Scripts Canada.
Clients who may require mental health counselling supports without appointments should discuss their needs with their mental health counselling provider and/or may wish to contact the Hope for Wellness Help Line as noted on page 1 of this guide.
3.2.2. Keeping client information up to date
Clients are responsible to keep their information up to date in order to avoid delays in payment/reimbursement, or in accessing NIHB benefits. In case of a name change or changes to any other personal information:
- To update First Nations status cards, clients should contact their local Band Office or Indigenous Services Canada Registration Services Unit at 1-800-567-9604.
- Inuit clients should contact their Land Claim Organization to update their personal information. Inuit living outside the Northwest Territories or Nunavut should also contact the NIHB program by sending an email to firstname.lastname@example.org.
- If a client's other benefit coverage (for example, private insurance) has changed, see section 3.8.3 Coordination of benefits on how to update their file.
3.2.3. Professional complaints
If clients have concerns regarding the counselling they receive, or the professional conduct of a counsellor, clients are encouraged to contact the provider's regulatory body directly. Mental health counsellors are health professionals who are regulated by Provincial/Territorial regulatory bodies and not employees of Indigenous Services Canada. The NIHB program will assist clients in finding another provider, and will cooperate in helping the regulator to investigate complaints.
Providers are obligated to notify the NIHB regional office and Express Scripts Canada when an official complaint is received (see section 2.3 Provider roles and responsibilities). Providers with an open investigation may be temporarily suspended pending resolution of the complaint. See the Non-Insured Health Benefits Mental Health Counselling Billing Agreement available on the Express Scripts Canada website.
3.3 Eligible services: Coverage and frequency guidelines
Every 12 months, NIHB clients are eligible for coverage of up to 22 hours of counselling performed by an NIHB-eligible provider consisting of:
- initial assessment (actual hours, up to a maximum of 2 hours). In order to facilitate timely access to services, these sessions are post approved*
- up to 20 hours of counselling, not including the initial 2 hours/assessment. Prior approval is required (see section 3.7 Prior approval process)
* Providers can initiate the initial assessment of up to 2 hours, for eligible clients, without obtaining prior approval. However, please note that when the provider submits a Prior Approval (PA) request, the assessment hours must also be included in order for these hour(s) to be paid as part of the claim for counselling services provided.
Additional hours in the same 12-month period may be covered on an exception basis. See section 3.5 Exceptions.
Services submitted for coverage must not be eligible for payment by another provincial/territorial, federal, or private plan or program, except in the case of coordination of benefits (see section 3.8.3 Coordination of benefits).
Mental health counselling providers should note that:
- only active counselling time is eligible for reimbursement. Note taking that is part of, or immediately follows, a client's session is considered active counselling time and forms part of the client's eligible hours (common practice is that a client is seen for 50 minutes and note taking is 10 minutes. This is billed as 1 hour of counselling). Note taking is not to be billed as a separate activity
- claims must be submitted for the actual counselling time (including the note taking) and not rounded up to the nearest hour. For example, if a client has a 30-minute session that includes the note taking, that is billed as 0.5 hours, or a 90-minute session is 1.5 hours
- billing by a provider may not exceed 8 hours of counselling services in one day (regardless of the number of clients served)
- mental health counselling providers may not bill the program for non-counselling hours spent with clients including for meals, transportation or social time
3.4 Types of eligible mental health counselling
All types of counselling (for example, group or individual counselling) count equally towards the client's 22 hours of total counselling eligible in a 12-month period.
The modality of treatment is to be determined by the provider, in accordance with practice standards and governing regulations set out by the applicable regulatory body. However, the NIHB program will not provide coverage for any items listed as exclusions in section 3.3 Exclusions.
Only services provided by an eligible provider directly to and for an eligible client will be eligible for coverage/reimbursement.
A provider may only bill for one client per session hour, with the exception of group counselling (refer to section 3.4.3 Group counselling),
Services eligible for reimbursement are as follows:
3.4.1 Assessment session(s)
An eligible mental health counselling provider may initiate the initial assessment/up to two (2) hours of counselling without prior approval, in order to determine and plan a course of treatment for the client. In order to facilitate timely access to services, the first session(s), up to two (2) hours are post-approved. Only the time spent actively assessing or counselling the client is eligible for reimbursement. Only services to an NIHB eligible client may be reimbursed.
3.4.2 Individual counselling
This is counselling provided to an NIHB client on a one-on-one basis. If the provider deems it necessary as part of counselling for the client receiving the treatment, another person such as a family member may be present during the counselling session(s). However, as noted earlier, counselling for non-NIHB eligible individuals may not be billed to the program.
If a family member participates (such as in a support or information-providing role), the session is to be billed as individual counselling to the primary client. No amount is to be billed for this other participant, regardless of their own eligibility under the NIHB program.
Providing counselling to more than one eligible client in the same session hour is considered a group counselling session to be billed at the group counselling rates (refer to section 3.4.1 Group counselling). If a number of family members who are eligible for NIHB coverage are participating in the same session, then the session is to be billed using the group counselling code and rate for each eligible client.
3.4.3 Couples/group of 2 counselling
This refers to cases where counselling is provided to 2 individuals in a group setting (such as a couple, or 2 members of a family). Claims for services for each eligible client are reimbursed at a rate equivalent to 50% of the individual counselling rate, as indicated in the Mental Health Counselling Benefit Grids, available on the Express Scripts Canada NIHB provider and client website. To have the cost for this type of counselling fully covered up to the maximum allowable, both participants must meet the eligibility criteria. In cases where only 1 of the 2 participants is NIHB-eligible, the program will cover 50% of the total cost of the group session/hour, up to the maximum. Note that only counselling for NIHB-eligible individuals can be billed to the program.
3.4.4 Group counselling
Counselling provided to multiple, eligible clients in the same session hour, where a client participates in active counselling along with other clients, is considered group counselling. It is normally part of a course of treatment that also includes individual (for example, one-on-one) counselling.
Group counselling session hours are to be billed at a rate per client that is no higher than permitted in the fee guide. No payment or administrative fee will be paid for running the group as a whole. Providers are to make a prior approval request and submit a claim for each eligible individual client, up to the maximum number of clients noted in section 188.8.131.52 Maximum group size eligible for reimbursement, for each hour the eligible client participates in the group.
Providers may not bill the NIHB program for group sessions already funded through other public programs or funding sources.
For situations where multiple NIHB eligible family members are participating in the same session and are all receiving counselling services, use the group counselling code.
184.108.40.206 Maximum group size eligible for reimbursement
While offering group counselling, providers are expected to follow a group size and manner no larger than is permitted by the standards established by their regulatory body. However, in order to support quality services to clients, and active participation by all, please note that the NIHB program will not accept claims for payment of more than 8 participants in any one group counselling session hour for one provider.
A larger format may be considered on an exception basis where multiple providers arrange to work together to provide a larger group format, while respecting an effective and appropriate client-to-provider ratio. The providers are to agree on which participants are the responsibility of which provider to avoid duplicate billing, and each provider may not bill for more than 8 eligible clients. Sessions for each eligible client may be billed by only one provider for each session hour at a rate not exceeding the group rate indicated in the applicable regional fee guide.
220.127.116.11 Ineligible group formats
Formats such as seminars, classrooms, camps or sessions held at camp, workshops or skills or other types of training sessions are not eligible for coverage as they are not considered to be mental health counselling.
Where an eligible provider has received prior approval for group counselling, this prior approval may not be used to claim for services of this type as they are ineligible services. Claims made for such services will not be paid and are subject to recovery if paid in error.
Communities should contact their FNIHB regional office to inquire regarding available supports if they are considering offering such services to their members.
Requests for counselling beyond the noted frequency or additional requests within the same 12-month period may be considered on an exception basis.
In cases where providers/clients are seeking such exceptional coverage, the provider is required to submit a rationale (through their online web account or directly to their regional office) for the additional hours, along with the completed Mental Health Counselling Prior Approval and Claim Form, available on the Express Scripts Canada NIHB provider and client website. The rationale must detail the frequency and duration of counselling required by the client, and the anticipated date of completion of the treatment plan in place for the client. Additional information may be sought on a case-by-case basis.
The following goods and services are exclusions which will not be covered by the NIHB program and are not subject to the NIHB program's appeal process:
- services provided to non-eligible individuals
- claims submitted on behalf of another provider, whether the provider and client are eligible or not. Providers may only submit claims under their own provider number
- claims submitted for missed/no-show or cancelled appointments
- other non-counselling time, such as "on-call" after-hour availability, waiting/travel time or administration (filing reports, making notes - other than note taking that is billed as part of a session, as noted in section 3.3 Eligible services: Coverage and frequency guidelines), or other non-counselling hours spent with clients such as meal(s), transportation, or social time
- any service by a non-eligible provider, regardless of its purpose (see section 2.1 Provider eligibility)
- professional or other fees for ceremony or other traditional practices carried out by the provider or another person (see section 1.1 Purpose of the guide for additional information on traditional healing in support of mental health counselling OR contact your local community for information on Elder and Traditional Healer services they may offer)
- services that are not mental health counselling/psychotherapy (including, but not limited to psychoeducational testing assessments, educational and vocational counselling, life skills training, life coaching/mentoring, early intervention/enrichment programs, sexual surrogacy/surrogate partner therapy, neuromodulation or other medical treatment such as psychedelic assisted psychotherapy)
- conversion therapy (any practice, treatment or service designed to change or repress a person's sexual orientation, gender identity/expression)
- accommodations and treatment fees for facility-based addictions treatment (publicly funded addictions treatment is available to eligible clients through the Indigenous Services Canada's Mental Wellness program or through programs funded by provincial or territorial governments. Contact the FNIHB regional office for more information on accessing these programs)
- services that have been submitted to or paid by the Indian Residential Schools Resolution Health Support Program. Claims are to be made either to the NIHB program or the Indian Residential Schools Resolution Health Support Program, but not both. See the Indigenous Services Canada website for more information on Indian Residential Schools Resolution Health Support Program
- services that are funded by another program or agency (such as counselling provided to incarcerated clients)
- psychiatric and family physician services insured through the provincial or territorial health plan
- services for the purpose of a third party (for example, school application, employment assessment, to support a legal action, child custody)
- costs to administer tests, such as license fee (only the professional time may be billed)
- community workshops, seminars or training
- any event that is a full-day in length, such as a day or weekend retreat, camps of any type, and workshops
- consultation or management advisory services (for example, policy, procedure review)
- telehealth through instant messaging, emails or apps
- the cost of cellular phones or cellular data
- subscription-based services (example, a monthly/annual fee for access to a therapist service on demand)
- claims for services funded by NIHB outside of Express Scripts Canada, for example, for services offered directly in the community (community managed services, or Indigenous Services Canada contracted visiting providers). Express Scripts Canada cannot process these claims.
3.7 Prior approval (PA) process
3.7.1 Fee-for-service and contracted services
With the exception of the first 2 hours of counselling, which may be post approved, or in exceptional circumstances, prior approval is required for all services. The prior approval process establishes the total number of hours approved and how these services will be delivered (individual, group, telehealth). Prior approval is intended to confirm:
- that the client is eligible for NIHB coverage
- that the provider is enrolled or eligible for enrolment
- the coverage that is available
- the maximum rate that will be paid for each session hour (providers must bill at their usual and customary rate, up to regional maximums published in the regional fee guide)
- that the client is not currently in active treatment with another provider for the same type of counselling (if so, prior approval may be considered on an exception basis)
The Mental Health Counselling Prior Approval and Claim Form and the Mental Health Counselling Regional Fee Grids are available on the Express Scripts Canada NIHB provider and client website. Providers with a NIHB web account may use it to submit PA requests.
Consideration of services beyond the annual eligibility frequency may be considered on an exception basis, by submitting a new prior approval including the information required as outlined in section 3.5. Exceptions.
Reimbursement for eligible services that have already been delivered but where prior approval was not sought in advance may also be considered for post approval. All such claims must include a fully completed Mental Health Counselling Prior Approval and Claim Form, available on the Express Scripts Canada NIHB provider and client website.
Prior approval requests will be assessed within 5 business days, 80% of the time, under normal circumstances, after receiving completed documentation requirements.
The 5-business day period starts from the date that the NIHB program receives the prior approval request and ends when the request is settled. The provider will be advised of the outcome of the prior approval process, by the method they have specified in their communications preferences.
Some clients may have access to NIHB or other federal or provincially funded mental wellness services provided in their community. In such cases, the provider(s) in their community would be considered the nearest appropriate provider (refer to section 5.1 Medical transportation). Requests to use a fee-for-service professional outside the community may be considered on a case-by-case basis. For more information or to find out if your community has this type of arrangement in place, please refer to Appendix D: Self-government and other community-managed benefit coverage or your NIHB regional office.
NOTE TO PROVIDERS: Only NIHB program officials have the authority to initiate or contract for services that are to be billed to Express Scripts Canada. Providers that have been requested to travel to a community to provide services must first confirm with the NIHB program regional office that any such services are eligible and make sure that prior approval is obtained for all such services in advance to confirm eligibility. Note that some First Nations or Inuit communities/organizations manage their own mental health benefit coverage under a Contribution Agreement and may initiate contracts/arrangements for eligible services. See Appendix D: Self-government agreements and other community-managed benefit coverage.
3.7.2 Community-managed services
Where a community manages and delivers NIHB mental health counselling benefits, it must have in place a prior approval process as described in their Contribution Agreement.
3.8 Claim submission
3.8.1 Fee-for-service claims
Eligible mental health counselling professionals in private practice who provide counselling services to NIHB-eligible clients may enroll to bill the program directly, through Express Scripts Canada. Processing of claims payments, including both provider claims and client reimbursements for the NIHB program mental health counselling benefit are done through Express Scripts Canada. More information can be found on the Express Scripts Canada NIHB provider and client website.
Providers are encouraged to enrol, and to send their claims directly to Express Scripts Canada for payment so that clients do not pay fees at the point of service. For many clients, balance billing and charging up front for services are barriers to accessing services.
Mental health counselling providers must be enrolled with Express Scripts Canada in order to bill the NIHB program directly for services provided to eligible First Nations and Inuit clients. Claims for payment, including both provider claims and client reimbursements, must be received by Express Scripts Canada within one year from the date of service to be eligible for payment. In order for the claim to be paid out, the service or item must be an eligible benefit and the client must have been eligible as of the date of service.
3.8.2 Community-managed services
As outlined in Appendix D: Self-government and other community-managed benefit coverage, some clients receive coverage for mental health counselling benefits through their community, health authority, or other government, and as such, these services are not reimbursed through Indigenous Services Canada. See also section 4.2 CIHB Administered by First Nations and Inuit Organizations of the Mental Health Counselling Claims Submission Kit, found on the Express Scripts Canada NIHB provider and client website.
3.8.3 Coordination of benefits
Clients are required to access any public (federal, provincial, or territorial) or private health coverage for which they are eligible prior to submitting their claim to the NIHB program through Express Scripts Canada.
It is the responsibility of the client to inform the provider if they have coverage through a private plan, such as a group health insurance plan.
When claiming expenses, having coverage under more than one plan allows clients to use both plans. When an NIHB-eligible client is covered by another plan, claims must be submitted to the other plan first. The other plan will typically provide an explanation of benefits (EOB) form that must be sent with the claim to Express Scripts Canada.
Clients may use their full NIHB coverage to pay any remaining balance for an eligible service after the other plan has paid. If a client has other insurance, the client's NIHB eligibility is not reduced. Any balance remaining after another plan has paid may be claimed, up to the client's full NIHB-eligible coverage amount.
Where a client is no longer eligible for coverage under another plan, or if there has been a change in the client's coverage through another plan, the client or provider can contact the NIHB regional office, or contact the NIHB Call Centre at Express Scripts Canada's client line at 1-888-441-4777, to update the coverage information on the client's file. Be prepared to indicate what benefits are affected by this change.
3.8.4 Provider reimbursement
Please note that claims will be paid when all the following criteria are met:
- the claim is for an eligible client and an eligible service
- the claim is for the amount of time that the client received counselling services (adjust the amount claimed if less time was used than was eligible)
- prior to being submitted to the NIHB program, the claim has been submitted to any alternate health plans (public or private) to which a client is eligible
- no portion of the claim has already been paid for by any other public program, or for which the provider has received alternate payment via salary or contract
- prior approval requirements are met
- fees charged are as approved on the Mental Health Counselling Prior Approval and Claim Form, and do not exceed the rates noted in the Mental Health Counselling Regional Fee Grid, both available on the Express Scripts Canada NIHB provider and client website
- a fully completed and signed Mental Health Counselling Prior Approval and Claim Form has been submitted to Express Scripts Canada
There will be no reimbursement for missed/no show or cancelled appointments.
Providers are to establish and maintain a system to keep a record, validated by the client, of each of the counselling hours utilized by the client. These records must be kept on file by the provider for claims validation purposes:
- For in person services, the provider must have the client sign a record in their file document confirming their attendance.
- For telehealth services, the provider must establish a means of capturing attendance, as noted in Appendix B: Coverage for mental health telecounselling.
Client validation is to be captured at the time of the appointment, not before. Such documents are to be retained and produced on request to validate their billings. Claim payments may be recovered when not supported by such documentation, as part of claims verification activities (see section 2.3 Provider Claim Verification Program).
Providers are encouraged to make regular submissions for claims payment. Claim forms received more than one (1) year from the service provision date will not be accepted and cannot be processed for payment.
Fees are inclusive of all associated administrative work. There is no separate reimbursement for the writing of any reports associated with the client file.
3.8.5 Client signature guidelines
It is not the program's role to collect client consent for treatment. A client signature obtained for claims submission purposes is not the means by which a client gives consent to his or her provider for treatment. This indicates only that the client understands their NIHB coverage and to confirm that they received the service that is being claimed on their behalf. The following client signatures are acceptable for this purpose:
- the signature of the client aged 18 or older, unless arrangements for alternative consent have otherwise been established for the client (for example, power of attorney for personal care, guardianship order)
- for clients between the ages of 14 to 18, where the provider is of the opinion that the client:
- has the capacity to understand what he/she is signing: the client may sign
- does not have the capacity to understand what he/she is signing: a parent or legal guardian may sign
- clients under the age of 14 should have a parent or legal guardian sign the forms. In exceptional circumstances, when a client under 14 years of age is unaccompanied by a parent or legal guardian, or the provider is of the opinion that the client has the capacity to understand what they are signing, a signature from the child may be accepted
3.8.6 Client reimbursement
While providers are encouraged to submit claims directly to Express Scripts Canada so that clients do not need to pay at the point of service, in some cases, clients may pay directly and seek reimbursement.
Requests for client reimbursement for mental health counselling benefits must be received within one (1) year of the date of service. More information on how to submit a claim for client reimbursement, instructions, links and to download the Client Reimbursement Form can be found on the NIHB Client Reimbursement webpage available on the Express Scripts Canada NIHB provider and client website.
Clients are encouraged to confirm what services and coverage amounts are eligible before paying out of pocket. The claim for reimbursement must meet all the program's eligibility criteria, including that the service was eligible and was provided by a mental health counselling professional eligible to be enrolled (see section 2.5 Provider enrolment process). Claims will be paid up to the amounts indicated in the Mental Health Counselling Regional Fee Grid for the province or territory where the service was delivered, which are published on the Express Scripts Canada NIHB provider and client website. Claims by ineligible providers or for ineligible services will not be reimbursed.
All requests for reimbursement submitted by mail or fax must include a completed NIHB Client Reimbursement Form, as well as original receipts. For submission via the web account, be sure to have a copy of the receipt to scan or take a photo to upload.
For some First Nations and Inuit clients, mental health counselling benefits coverage is managed and delivered by a First Nations or Inuit community, organization, regional health authority or other government. For more information, see Appendix D: Self-government and other community-managed benefit coverage.
4.0 Appeal process
Persons eligible for the NIHB program have the right to appeal the denial of a benefit with the exception of items and services that are identified as exclusions (refer to section 3.0 Exclusions). More information about the appeal process is available on NIHB's webpage Appealing a decision under the NIHB program or by contacting your NIHB regional office.
5.0 Medical transportation
Medical transportation benefit coverage may be provided to the nearest appropriate provider or support may be available so that a provider can travel into a community to provide services when it is deemed more cost-effective. All travel must be pre-approved. Contact your NIHB regional office or your community to request prior approval of travel requests.
Medical transportation support will be provided to the nearest appropriate provider. Exceptions may be considered to provide coverage for travel to access a provider with a specific area of expertise, including where the provider may have specific cultural competence experience or training.
For more information on eligible medical transportation coverage, please refer to the NIHB's Medical Transportation Policy Framework.
6.0 Mental health counselling benefits resources
6.1 Contact information
For additional information on NIHB mental health counselling benefits, or assistance finding an enrolled mental health counselling provider, contact your local NIHB regional office.
If the client receives health benefits coverage under a separate agreement, please refer to Appendix D: Self-government and other community-managed benefit coverage for contact information.
6.2 Mental health counselling programming
Many municipalities or other local governments, and provincial or territorial governments offer mental health counselling programming, for example, through non-profit organizations such as the Canadian Mental Health Association or local Aboriginal friendship centres.
Through its Mental Wellness programming, Indigenous Services Canada administers contribution agreements and transfers direct departmental spending to support culturally appropriate community-based programs, services, initiatives and strategies related to the mental wellness of First Nations and Inuit clients. The range of services includes prevention, early intervention, treatment, and aftercare. Key services supporting program delivery include: substance abuse prevention and treatment (part of the Canada Drugs and Substances Strategy), mental health promotion, and suicide prevention. The Mental Wellness program objective is to address the greater risks and the lower health outcomes associated with the mental wellness of First Nations and Inuit individuals, families and communities.
Appendix A: Eligible providers by province and territory
Please note that health professionals are regulated at the provincial or territorial level; there are no national legislated regulatory bodies for mental health counselling providers. As a result, not all professions are recognized in all provincial/territorial jurisdictions.
Mental health professional licensing varies between jurisdictions, and in order to enrol with NIHB, providers must be a legally regulated health professional, licensed under provincial or territorial law to practice mental health counselling (psychotherapy) in the province or territory where the client is located.
The following tables outline which professionals are recognized, by province/territory:
|Province||Legislated regulatory body and professional designation|
|British Columbia||British Columbia College of Social Workers
|College of Psychologists of British Columbia
|British Columbia College of Nurses and Midwives
|Alberta||Alberta College of Social Workers
|College of Alberta Psychologists
|College of Registered Psychiatric Nurses of Alberta
|Saskatchewan||Saskatchewan Association of Social Workers
|Saskatchewan College of Psychologists
|Registered Psychiatric Nurses Association of Saskatchewan
|Manitoba||Manitoba College of Social Workers
|Psychological Association of Manitoba
|College of Registered Psychiatric Nurses of Manitoba
|Ontario||College of Psychologists of Ontario
|Ontario College of Social Workers and Social Services Workers
|College of Registered Psychotherapists of Ontario
|College of Occupational Therapists of Ontario
|College of Nurses of Ontario
|Québec+||"Ordre des psychologues du Québec"
|New Brunswick||College of Psychologists of New Brunswick
|New Brunswick Association of Social Workers
|College of Counselling Therapists of New Brunswick
|Nova Scotia||Nova Scotia Board of Examiners in Psychology
|Nova Scotia College of Social Workers
|Nova Scotia College of Counselling Therapists
|Prince Edward Island||Prince Edward Island Psychologists Registration Board
|Prince Edward Island Social Work Registration Board
|The College of Counselling Therapy Prince Edward Island
|Newfoundland and Labrador||Newfoundland and Labrador Psychology Board
|Newfoundland and Labrador College of Social Workers
|Yukon||Government of Yukon (Registered Psychiatric Nurses Advisory Committee)
|Nunavut/Northwest Territories||Not enrolled, except providers in Northwest Territories may be enrolled to serve Alberta border clients. Service managed by Territorial Gov't for territorial client (these clients may access services in the south when they are "out" for other appointments)|
|* Only where the license is for unsupervised, independent practice.
~ These are equivalent "Psychotherapist" designations for the purposes of the NIHB program eligibility.
+ Any provider licensed in QC must have a Psychotherapy permit issued by the "Ordre des psychologues du Québec".
α Must meet their own regulatory body's requirements to offer Psychotherapy.
On an exception basis only, other types of providers may be enrolled at the discretion of Indigenous Services Canada when ALL of the following conditions apply:
- The provider has been certified by a non-legislated entity that functions as a self-regulatory body (see **)
- In the opinion of Indigenous Services Canada (ISC), there are an insufficient number of legislated providers enrolled with the NIHB program in the vicinity, limiting access to services (the exception provider's practice is limited to serving such communities)
Such providers are enrolled only on an exceptional, case-by-case, time-limited basis at the determination of ISC.
**One credential that may be considered in exception enrolments is the Canadian Certified Counsellor (CCC) credential issued by the Canadian Counselling and Psychotherapy Association (CCPA). However, note that membership in the CCPA is not sufficient, and is not recognized by the NIHB program for the purpose of enrollment as an exception provider.
Note to providers: if you are a regulated health professional such as a psychologist, do not enrol using your CCC or other exception credentials.
Appendix B: Coverage for mental health telecounselling
Mental health counselling services provided virtually (for example, the use of video-conferencing or telephone to deliver mental health counselling services) are eligible for coverage. Please note that asynchronous models such as instant messaging, email or subscription-based services are not eligible for reimbursement.
Mental health telecounselling is an evolving field, and policies surrounding its use and coverage are being reviewed on an ongoing basis.
Coverage for mental health telecounselling is only provided if the client receiving mental health counselling agrees to its use. The provider must return to face-to-face counselling at any time the client wishes to do so. Please note, the medical transportation (MT) benefit supports eligible clients in accessing medical services at the nearest appropriate location (available health professional or facility). Clients who need to travel beyond the nearest appropriate provider for face-to-face service provision will not be eligible for MT through NIHB, and may need to be supported in transitioning to a new provider.
Interprovincial mental health telecounselling (where the provider and client are in different provinces) may be considered on an exception basis only (refer to Appendix C: Interprovincial mental health telecounselling).
In using mental health telecounselling, providers are responsible to ensure that its use:
- meets the standards and code of ethics of the respective legislated regulatory bodies and provincial or territorial regulations in the provision of mental health counselling services through telehealth, including client privacy and confidentiality
- in situations where the provider and the client are in different jurisdictions, the provider must:
- ensure that their own regulatory body permits the provision of services to clients in another jurisdiction and must follow all associated requirements to do so
- ensure they meet all the requirements of the regulatory body in the jurisdiction where the client will receive the service (for example, some jurisdictions may require that a provider from another province or territory register for approval to provide services in this way)
- follows the Model Standards for Telepsychology Service Delivery (found on the ACPRO website) adopted by the Association of Canadian Psychology Regulatory Organizations (ACPRO) in provinces or territories where a provider's regulatory body does not have guidelines for the provision of telehealth
- determine, with the client, the suitability of telehealth services for delivering mental health counselling services for the client, taking into account potential privacy issues and client's technical capacity. This determination should be based on the provider's professional judgment and take into consideration such factors as client's needs, safety and the accomplishment of therapeutic goals
- ensure their ongoing competence with service delivery technologies for mental health telecounselling, and mitigate any potential negative impacts of the technology on the client
- the technology (for example, computer/video conferencing or telephone) and location (for example, nursing station, community health centre, or other) used to provide counselling services will be determined by the provider based on the client's case, and in accordance with the provider's regulation related to the delivery of telehealth services
- the provider must have a process in place to confirm the client's attendance such as a telephone log, attendance sheet or email confirmation (depending on the modality) and must maintain client attendance records for claim verification purposes (note that claims for mental health telecounselling services which are not supported by client attendance records may not be reimbursed or may be subject to reclaim)
- the cost of the equipment, data, etc. are the responsibility of the provider
- the cost of cellular phones or cellular data plans or packages are not an eligible benefit
Initial client assessments should generally be undertaken in-person. In exceptional circumstances, coverage for assessment via telehealth may be approved.
Please also refer to the terms and conditions as outlined in the Mental Health Counselling Billing Agreement found in the Mental Health Counselling Professional Provider Enrolment Package on the Express Scripts Canada NIHB provider and client website.
Appendix C: Interprovincial mental health telecounselling
In exceptional circumstances, the NIHB program may allow enrolment of providers for virtual telehealth services in another region.
Please direct questions on telehealth services to the region where the client resides.
Please note that providers outside of Canada are not eligible to enrol, and clients who do not reside in Canada are not eligible to receive coverage.
Eligible professionals are enrolled to provide services to clients living in the province or territory where they practice. Services to clients in another province or territory may only be provided when prior approval is obtained from the regional office, and the provider is also specifically registered in good standing with a regulatory body in another province or territory for professionals listed in Appendix A: Eligible providers by province and territory, or has written authorization from the appropriate regulatory body where client obtains the service. Service provision must be for the purposes of providing mental health counselling via telehealth (for example, phone or video), and must align with the policy outlined in Appendix B: Coverage for mental health telecounselling.
Enrolment to provide such services to clients in another jurisdiction is only permitted on an exception basis, and claims to provide such services, may be considered on a case-by-case basis where the following requirements are met:
- the provider must be permitted (by provincial/territorial law and regulation) to practice as a regulated health professional in the province where the client is located, specifically:
- the regulatory body must permit the professional to practice in that jurisdiction (typically, the professional provider must be licensed to practice in that location, including meeting any special license requirements for virtual service providers from other jurisdictions, where such requirements exist)
- the professional's designation must be recognized as a regulated health professional under the applicable provincial or territorial regulations*
- the provider's home regulatory body permits the provision of services to clients outside the home jurisdiction, and the provider is insured to do so:
- it is the provider's responsibility to ensure and to document that these requirements are met
Note that, where a client has, on an exceptional basis, been receiving mental health telecounselling from an eligible provider who is physically located in a different jurisdiction (province or territory), if a return to in-person counselling is requested, medical transportation benefit coverage will not be provided to access in-person counselling services beyond the nearest appropriate provider, in accordance with the NIHB Medical Transportation Policy Framework.
Appendix D: Self-government agreements and other community-managed benefit coverage
Some First Nations and Inuit clients receive their health benefits through other agreements (for example, self-government agreements, other funding agreements). For these clients, their mental health counselling benefits coverage is managed and delivered by a First Nations or Inuit community, organization, regional health authority or other government. Please note that these requests are not processed by Express Scripts Canada or the NIHB program. Clients and service providers can contact the responsible organization listed here for information about coverage and claims payment/ reimbursement of benefits for these clients.
Services to clients of the following First Nations, Inuit Land Claim Organizations, Health Authorities and/or Self-Governing entities are not managed by the NIHB program and cannot be processed by Express Scripts Canada. Please note that this list is not exhaustive and continues to evolve. Please contact the NIHB regional office if you have questions about a particular client case:
|Nisga'a citizens* (anywhere in Canada)||Nisga'a Valley Health Authority
1 (888) 233 2212
Website: Nisga'a Valley Health Authority
|Registered First Nations individuals who reside in British Columbia (including when travelling outside of BC)*||BC First Nations Health Authority (FNHA)
1 (855) 550-5454
Website: BC First Nations Health Authority
|Bigstone Cree Nation* (anywhere in Canada)||Bigstone Health Commission
1 (877) 767-7060
Website: Bigstone Health Commission
|James Bay Cree living in the James Bay catchment area*||Cree Board of Health and Social Services of James Bay
1 (819) 855-2744
Website: Cree Board of Health and Social Services of James Bay
|Naskapi of Kawawachikamach, living in the catchment area*||Naskapi of Kawawachikamach
1 (418) 585-2110
|Nunavik residents (Makivik Corporation), living in Nunavik*||Nunavik Regional Board of Health and Social Services
1 (844) 964-2244
Website: Nunavik Regional Board of Health and Social Services
|Nunatsiavut land claim beneficiary (Labrador Inuit Land Claim Agreement)* (anywhere in Canada)||Nunatsiavut Government
1 (709) 922-2942
Website: Nunatsiavut Government
|Qalipu First Nation clients (if accessing services in the Atlantic provinces: NB, NS, PE, NL)||Qalipu First Nation
1 (855) 675-5743
Website: Qalipu First Nation
For NIHB clients living in Nunavut or the Northwest Territories, mental health counselling services are managed by the territorial governments, and the NIHB program does not process claims for in-territory services. However, clients living in these territories who access mental health counselling services when out of territory should contact the NIHB office in the region where they obtained services for assistance in submitting a claim.
*Clients served under a separate agreement will be marked as ineligible in NIHB's claims processing system. For clients who were previously living in BC, James Bay or Nunavik who have moved and now reside elsewhere in Canada, please contact the NIHB regional office for assistance to update the client's file. The client's status will not be modified for temporary absences.
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