1.0 General policies

These are the general policies of the Indigenous Services Canada (ISC) Non-Insured Health Benefits (NIHB) Medical Supplies and Equipment (MS&E) benefits. Use the general policies in combination with specific policies found within the benefit lists sections 2.0 to 13.0.

Table of contents

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:

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:

1.4 Types of MS&E benefits

1.4.1 Open benefits

Open benefits are medical supplies and equipment that can be obtained without prior approval.

Client eligibility must be established before submitting a claim for any benefits. Providers must contact the Express Scripts Canada Provider Claims Processing Call Centre at 1-888-511-4666 to confirm the client eligibility. Once eligibility has been confirmed, claims may be submitted directly to Express Scripts Canada for payment.

The following information must be kept on file:

  • prescription or written recommendation from an NIHB-recognized prescriber/recommender
  • manufacturer product code number, make/model of the equipment
  • assessment or written recommendation report from a health professional, if available

1.4.2 Limited use

Limited use (LU) benefits are medical supplies and equipment that require the client to meet specific criteria for coverage. To receive benefits in this category prior approval must be obtained from the NIHB regional office.

1.4.3 Exceptions

Exceptions are medical supplies and equipment that are not currently listed on the NIHB Medical Supplies and Equipment Benefit Lists. Coverage may be provided on a case-by-case basis for items not listed under exclusions. Prior approval must be sought with written medical justification from the NIHB regional office.

1.4.4 Exclusions

Exclusions are medical supplies and equipment that are not listed on the NIHB Medical Supplies and Equipment Benefit Lists and cannot be considered for coverage or appealed. Exclusions are items that do not fall within our mandate including but not limited to:

  • items used exclusively for sports, work or school
  • items for cosmetic purposes
  • experimental equipment and/or experimental therapy
  • therapy treatment (for example: Occupational Therapy, Physiotherapy, Speech Therapy, Chiropractic, Massage Therapy, etc.)
  • therapy equipment (for example: treadmills, exercise balls, etc.)
  • household items/products (for example: cleaning supplies, furniture, security systems, internet, etc.)
  • home renovations (for example: ramps, stair lifts, etc.)
  • medical treatment (for example: surgery, insured or not)

Examples listed under general headings are not exhaustive. If unsure of coverage please contact the NIHB regional office. Some, more specific, exclusions may also be found under each of the benefit lists.

1.5 Prescription requirements for MS&E items

Prescriptions and written recommendations from NIHB approved prescribers must:

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:

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:

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:

1.10 Repairs

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

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:

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:

1.12.1 Provider

NIHB providers must read and retain a copy of the most current version of the Medical Supplies and Equipment Claims Submission Kit located on the Express Scripts Canada website. This Kit outlines provider accountability and obligations when submitting claims for payment. When an updated Medical Supplies and Equipment Claims Submission Kit is posted to the Express Scripts Canada website, there is reference to the new Kit in the Medical Supplies and Equipment Newsletter. Notification of Kit updates are posted thirty (30) calendar days prior to the circulation date.

1.12.2 Client reimbursement

Many providers are enrolled with NIHB and paid directly by the program, so clients do not have to pay out of pocket for eligible benefits. We recommend that before you receive any item or service, you should confirm with the provider that they are enrolled with NIHB and will bill us directly, that the item or service is eligible for coverage, and that the provider will not charge you any additional fees.

Client who decides to pay the full cost of an item and request a reimbursement from the program should contact the Express Scripts Canada website or the NIHB regional office prior to purchase to confirm eligibility for item coverage and the amount covered by the program.

Find additional information at NIHB Client Reimbursement.

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:

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:

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:

In such cases, the custom-made item:

In cases, where the item is a special order:

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:

Client Phone Number:

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

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