1.0 General policies

1.1 Introduction

Indigenous Services Canada (ISC)'s Non-Insured Health Benefits (NIHB) program is a national program that provides eligible registered First Nations and recognized Inuit coverage for a range of medically necessary health benefits when these benefits are not otherwise covered through private or provincial/territorial health insurance plans or social programs.

The NIHB program provides clients (registered First Nations and recognized Inuit) with coverage for a range of health benefits, including prescription drugs and over-the-counter medications, dental and vision care, medical supplies and equipment (MS&E), mental health counselling, and transportation to access health services not available locally.

Items covered through the MS&E benefit are intended to address our clients' medical needs in relation to basic activities of daily living (ADL) such as eating, bathing, dressing, toileting and transferring.

Policies and guidelines are established in accordance with our mandate and the mandate of the First Nations and Inuit Health Branch. NIHB benefit coverage is based on the recommendation of NIHB recognized health professionals and is consistent with the best practices of health services delivery and evidence-based standards of care.

Changes in policy will be made here and highlighted in regular NIHB program updates. Providers will be notified of changes through Express Scripts Canada bulletins and newsletters.

If you wish to enroll as an NIHB provider, refer to the Express Scripts Canada website for more information.

Providers and clients who do not have access to the internet can contact the NIHB Call Centre at Express Scripts Canada to request a copy of the documents mentioned above. All questions or comments regarding the Kit should also be directed to the NIHB Call Centre at Express Scripts Canada by calling their toll free number at 1-888-511-4666.

1.2 Client eligibility

To be eligible for NIHB program benefits, a client must be a Canadian resident, and identify as one of the following:

• a First Nations person who is registered under the Indian Act (commonly referred to as a "status Indian")

  OR

• an Inuk recognized by one of the following Inuit Land Claim organizations: Nunavut Tunngavik Incorporated, Inuvialuit Regional Corporation, Makivik Corporation. For an Inuk residing outside of their land claim settlement area, a letter of recognition from one of the Inuit land claim organizations and a birth certificate are required

  OR

• an infant, less than 18 months of age, whose parent is an eligible client

  AND

• is currently registered or eligible for registration, under a provincial or territorial health insurance plan

  AND

• is not otherwise covered under a separate agreement (for example, a self-government agreement such as the Nisga'a and Nunatsiavut agreements) with federal, provincial or territorial governments

Please note: to be eligible for reimbursement, the good and services must be obtained in Canada from a business that is located in Canada.

1.3 Terms and conditions of services

Providers responsibilities:

• adhere to all criteria and policies as:
  • posted on NIHB for First Nations and Inuit website
  • posted for NIHB providers on Express Scripts Canada website
  • listed in the Medical Supplies and Equipment Claims Submission Kit found on the Express Scripts Canada website
  • written in the MS&E Billing Agreement found in the NIHB Medical Supplies and Equipment Provider Enrolment Package on the Express Scripts Canada website
• check the Express Scripts Canada website regularly for bulletins, newsletters and alerts
• inform Express Scripts Canada immediately should any change of provider information occur
• verify client is eligible for NIHB Benefits and is not already covered by a public or private health plan
• retain all applicable supporting documentation for benefit approval including:
  • prescription or written recommendation from an NIHB-recognized prescriber/recommender
  • medical assessments
  • order sheets
  • invoice from manufacturer
  • explanation of benefits
  • other documents as required by NIHB
• assess client or review assessment provided by the prescriber to determine the most efficient MS&E item required by the client
• submit Prior Approval Forms, found on the Express Scripts Canada website
• completed in full with required documentation and obtain prior approval where required prior to dispensing item
• dispense items only when requested by client or caregiver
• dispense items at a maximum three-month supply at a time
• claim reimbursement only after item has been dispensed to the client (in person or through trackable delivery) and item has been received in complete functioning order with further instructions in MS&E Claims Submission Kit found on Express Scripts Canada website
• advise clients of claim status and direct clients to Express Scripts Canada website or NIHB for First Nations and Inuit website for coverage information as needed
• maintain a liability insurance which is standard with industry or regulatory bodies
• assist clients with appeal requests
• participate and cooperate in any and all quality assurance programs and procedures established by Express Scripts Canada or required by Indigenous Services Canada (ISC) including but not limited to:
  • peer review
  • credentialing/re-credentialing processes
  • claim verification systems
  • complaint resolution procedures
• abide by, comply with and carry out all determinations resulting from any quality assurance program or procedure
• acts in accordance with all applicable laws, and the standards of practice required by their professional regulatory authority
• the provider shall provide services to all clients who are eligible under the NIHB program unless, in the provider's reasonable professional judgment, such services should not be provided. In the event this occurs, the provider shall keep a record of the circumstances of the decision not to provide services to the applicable client
• the provider must maintain records related to clients and their MS&E benefits coverage history for the time period in accordance with all applicable laws, but not less than five (5) years

1.4 Types of MS&E benefits

1.5 Prescription requirements for MS&E items

Prescriptions and written recommendations from NIHB approved prescribers must:

• be written for an individual client
• be written and dated before the service date
• not be initiated or written by the service provider and supplied to the prescriber for signature
• be provided for both the initial and replacement items (unless otherwise indicated in the benefit lists)
• contain all of the following information:
  • written date (valid for 12 months unless otherwise indicated)
  • the health professional's license number
  • health professional's unique hand-written signature
  • client's full given name(s) and surname
  • quantity and type of item or service being prescribed/recommended

Faxed prescriptions/written recommendations must be sent directly from the health professional to the provider and require a fax header with the date sent and the sender's coordinates.

Prescriptions not meeting all requirements will be deemed invalid.

1.6 Prior approval process

In order to ensure clients are receiving appropriate supplies and equipment that will meet their medical needs, some MS&E items require prior approval for reimbursement. Items for eligible clients requiring prior approval must only be dispensed after the approval has been granted by the NIHB regional office.

To receive a prior approval, the provider must:

• retrieve the benefit specific prior approval form from Express Scripts Canada
• complete the entire prior approval form
• submit the completed prior approval form to the NIHB regional office; for the region in which the provider is located; with the following attachments:
  • client's written prescription, recommendation or referral from a physician, nurse practitioner, or an NIHB-recognized health professional for the benefit required
  • copy of any applicable third-party coverage (for example: motor vehicle insurance, workers' compensation board, private insurance, etc.)
  • copy of any applicable tests and reports required as outlined in the benefit lists or on the prior approval form
  • any additional supporting documents that will substantiate the clients need for the benefit item.

Incomplete prior approval forms will result in delay of the approval.

We reserve the right to request additional information if deemed necessary to adjudicate prior approval requests.

No fees will be paid in relation to completing prior approval forms or documents to support prior approval.

1.7 Special authorization

A special authorization (SA) is a type of prior approval that may be provided for items required on a long-term basis that have a set price and recommended replacement guidelines.

Claims against the special authorization are submitted directly to Express Script Canada for the approved duration without requiring additional prior approval. Please note that the prior approval number should not be included in the billing if there is a special authorization assigned as this will cause adjudication errors.

1.8 Recommended replacement guidelines

Recommended replacement guidelines are based on a combination of the usual and customary medical needs of clients and the customary device lifespan. Recommended replacement guidelines are listed on the benefit lists. Requests exceeding these guidelines may be considered on a case-by-case basis when supported by clinical rationale from a recognized health professional.

Early replacement of equipment and devices require prior approval and will be considered when one of the following has occurred:

• a substantial unanticipated change has taken place in a client's medical condition (for example, substantial change in weight and/or growth, etc.)
• the equipment or device is outside of warranty, has deteriorated during the course of a normal use and cannot be repaired in a cost effective manner

Early replacement will not be considered for items that have been damaged as a result of misuse, carelessness or negligence.

1.9 Rentals

When an MS&E item is rented, the rental agreement must:

• not exceed 3 months
• not exceed the cost of purchase
• rental rates are inclusive therefore it should include accessories, supplies (except where indicated in the benefits lists), all equipment maintenance, setup, education, cleaning, adjustments, replacement parts, repair, and labour
• stipulate that should the purchase of the item become an option, the amount spent on the rental will be deducted from the purchase price

1.10 Repairs

Repairs may only be paid when the following criteria are met:

• the warranty on the item has expired
• the item being repaired has not already been replaced by a newer item
• it is more cost effective than replacing the item
• they restore the item's physical condition, allowing for normal wear and tear, and include a warranty according to industry standards
• prior approval has been received

A prescription or written recommendation is not required for repairs.

Note: Repairs will not be covered if items are damaged as a result of misuse, carelessness, or negligence.

1.11 Warranties

As a provider you are expected to serve as the client's advocate to request that the manufacturer or manufacturer's service depot honour the warranty on the item.

Providers must agree that during the duration of the warranty:

• repairs and services are the responsibility of the provider, manufacturer, or service designate free of charge to the program
• in situations where there are repeated technical failures, the item, device or components will be replaced by the provider at no cost to the NIHB program

1.12 Claims submission

The NIHB program has established a price file for certain items. The prices are listed on the Express Script Canada website. Please note that these prices do not apply to provider groups with whom NIHB has existing agreements.

Please note:

• when a price is established by the program, the price is all inclusive and the markup field is left blank on the claim form when submitting for payment
• markup does not apply to any delivery charges any taxes or any labor costs

1.13 Coupons and promotions

Eligible clients may not directly or indirectly benefit from special promotions or incentives offered by providers.

To the extent permitted by such promotions and applicable law, coupons, discounts, or rebates, should be applied to the NIHB claim. As a result, the amount claimed is the residual amount after the application of the promotion.

1.14 Coordination of benefits

Clients that are covered by another public or private health care plan must first submit their claim to the other health care/benefits plan.

The NIHB program will:

• require a copy of the Explanation of Benefits form supplied by the other public or private health care plan to confirm that all other health coverage has been exhausted
• respect the prescribing requirements of the other plan/program
• continue to apply NIHB criteria for coverage
• coordinate an amount up to the full coverage of the item
• require a copy of the health care plan message indicating refusal to coordinate should the other plan refuse to coordinate with NIHB
• coordinate payment with the other payer on eligible benefit(s) either manually or electronically

Requests for a co-payment to upgrade an item will not be accepted.

If the client no longer has alternate health coverage, the client or the provider should contact the NIHB regional office so that the client's file can be updated.

1.15 Balance billing

Items meeting eligibility criteria will be covered in full according to NIHB Price files or maximum eligible costs set by the program. Coverage is not provided to upgrade a benefit.

Providers shall not:

• bill clients co-payment or extra charges
• collect a deposit
• seek compensation from a client
• condition the provision of services on payment from a client
• have any recourse against any client or person acting on behalf of the client

Providers may charge a client upfront only in a co-ordination of benefits situation or when an item is not covered by the NIHB program.

1.16 Unclaimed MS&E items

A partial reimbursement may be requested for custom-made or special-order items in situations where one of the following occurs:

• client does not pick up the item
• client is unable to use the item due to a changed or improved condition
• client passed away after the completion of the order but prior to the dispensing

In such cases, the custom-made item:

• is dismantled and an invoice is submitted for the custom-made parts that cannot be reused, as well as for professional fees incurred for the creation of the item as per prior approval

In cases, where the item is a special order:

• an invoice is submitted for any re-stocking fees and shipping costs associated with returning the item to the manufacturer
• the item should be returned to the manufacturer/supplier if the client cannot be reached before the end of the period provided by the manufacturer/supplier's return policy

In cases where the client does not pick up the item, the provider should make a reasonable effort to contact the client. Attempts to contact the client should be documented in the client's file. Each submission will be reviewed on a case-by-case basis. Contact the NIHB regional office to submit a claim for a restocking fee (code 99401097).

1.17 Privacy statement

The NIHB program has a responsibility to protect personal information under its control in accordance with the Privacy Act, related Treasury Board privacy policy and directives and is responsible for ensuring 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 aadnc.atiprequest-airprpdemande.aandc@canada. 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.

1.18 Appeal process

If a benefit request has been denied, it may be appealed provided that it falls within the mandate and has not been identified as either an exclusion or an insured service. More information is available on the NIHB Appeal Process page.

1.19 Audit program

The audit program:

• ensures accountability for expenditure of public funds
• performed by the Health Information and Claims Processing Services (HICPS) contractor
• confirms claims have been billed in compliance with the terms and conditions of the NIHB program
• detailed information about audit procedures and the responsibilities of providers for these audits are included in the Medical Supplies and Equipment Claims Submission Kit found on the Express Scripts Canada website page.

1.20 Contact information

For information on billing contact Non-Insured Health Benefits Call Center at Express Scripts Canada.

Provider Phone Number:
1-888-511-4666

Client Phone Number:
1-888-441-4777

For more information on benefits and policies, contact the Non-Insured Health Benefits program at your applicable NIHB regional office.