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 benefits include prescription drugs and over-the-counter (OTC) medications, dental and vision care, medical supplies and equipment (MS&E), mental health counselling, and medical transportation to access medically required health services that are not available on the reserve or in the community of residence.

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 in bulletins and newsletters available on the Express Scripts Canada website.

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, 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 Your Health Benefits - A Guide for Inuit to Access Non-Insured Health Benefits
• a child less than 18 months of age, whose parent is an NIHB-eligible client

Refer to the NIHB client eligibility webpage or contact the NIHB regional office for information.

More detailed information about the identification and eligibility of clients is also provided in section 4. Client Identification and Eligibility of the Medical Supplies and Equipment Care Claims Submission Kit available on the Express Scripts Canada website.

1.3 Terms and conditions of services

Providers responsibilities:

• adhere to all criteria and policies as:
  • posted on the NIHB for First Nations and Inuit website
  • posted for NIHB providers on the 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 the Express Scripts Canada website
• advise clients of claim status and direct clients to the 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 the Express Scripts Canada website
• 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 Scripts 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
• coverage for the cost of stolen items or items damaged by an unforeseen event (for example, fire, flooding, etc.) may be considered with justification and supporting documentation of the incident that caused the need for replacement (such as an incident, insurance, medical or police report citing the incident). If it is not possible to produce a fire incident or police report, the region must be informed and a request for prior approval must be submitted for coverage of the cost to replace the item

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 Scripts 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 pricing guidelines 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

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. If an approved item is not picked up after 30 days, it must be returned to the provider inventory. The provider can claim for reimbursement only when the equipment or supply is dispensed to the client.

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 worsening 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

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 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 claim verification procedures is included in section 6. Provider Claim Verification Program of the MS&E Claims Submission Kit available on the Express Scripts Canada website.

1.20 Contact information

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

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.