1.0 General policies
Effective date: September 14, 2022
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.
- 1.1 Introduction
- 1.2 Information for clients
- 1.3 Client eligibility
- 1.4 Providers with MS&E specialties
- 1.5 Terms and conditions of services
- 1.6 Types of MS&E benefits
- 1.7 Prescription requirements for MS&E items
- 1.8 Prescriber/recommender requirements
- 1.9 Prior approval process
- 1.10 Special authorization
- 1.11 Coverage of supplies, maintenance, and repairs of medical equipment covered by another benefit plan or purchased by the client
- 1.12 Recommended replacement guidelines
- 1.13 Rentals
- 1.14 Repairs
- 1.15 Warranties
- 1.16 Claims submission
- 1.17 Coupons and promotions
- 1.18 Coordination of benefits
- 1.19 Balance billing
- 1.20 Unclaimed MS&E items
- 1.21 Privacy statement
- 1.22 Appeal process
- 1.23 Provider Claim Verification Program (PCVP)
- 1.24 Contact information
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 newsletters and bulletins, available on the Express Scripts Canada NIHB provider and client website.
If you wish to enrol as an NIHB provider, refer to the provider enrollment webpage, found on the Express Scripts Canada NIHB provider and client website.
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 MS&E Claims Submission Kit, found on the Express Scripts Canada NIHB provider and client website, 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 Information for clients
Providers enrolled with NIHB are paid directly by the program so that clients do not have to pay out of pocket for eligible benefits. Prior to purchasing an item or a service, the client should confirm the following:
- the provider is enrolled with NIHB
- the provider will bill the program directly
- the item or service is eligible for coverage, and
- the provider will not charge the client any additional fees
For information on client reimbursement, please refer to section 1.16.2 Client reimbursement.
1.3 Client eligibility
The provider must verify that the individual is eligible for benefits under Indigenous Services Canada's NIHB program and 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 Who is eligible for the NIHB program webpage or contact the NIHB regional office for more information.
More detailed information about Client Identification and Eligibility can be found in section 4 of the MS&E Claims Submission Kit, available on the Express Scripts Canada NIHB provider and client website.
1.4 Providers with MS&E specialties
- Providers dispensing specialty MS&E items must indicate the specialty items they wish to dispense on the Provider Billing Agreement form. The required qualifications to dispense such specialty items must be submitted to Express Scripts Canada as part of the enrolment process, upon request. This includes licenses, certificates, and diplomas which support the credentials required for such specialty items
- All information related to specialty items including credentials for specialty items/services must be kept in the client file. This may be requested at any time, including the prior approval process
|Audiology||Audiology services and hearing devices||
|Compression and burn garments||Compression garment, hypertrophic scan (burn) garments, lymphedema compression devices||
|Custom-made shoes and custom-made foot orthotics||Custom-made shoes and custom-made foot orthotics||
|Limb and body orthotics||Limb and body orthotics – Class 2 (custom-fit) and Class 3 (custom-made)||
|Oxygen||Oxygen supplies and equipment||
|Respiratory supplies and equipment||Respiratory supplies and equipment||
1.5 Terms and conditions of services
- 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 NIHB provider and client website
- listed in the MS&E Claims Submission Kit, found on the Express Scripts Canada NIHB provider and client website
- written in the MS&E Billing Agreement, found in the NIHB Medical Supplies and Equipment Provider Enrolment Package on the Express Scripts Canada NIHB provider and client website
- check the Express Scripts Canada NIHB provider and client website regularly for bulletins, newsletters and alerts
- inform Express Scripts Canada immediately should any change of provider information occur by contacting the NIHB Call Centre at Express Scripts Canada
- verify client is eligible for NIHB benefits and is not already covered by a public or private benefit 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 NIHB provider and client 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 the MS&E Claims Submission Kit, found on the Express Scripts Canada NIHB provider and client website
- advise clients of claim status and direct clients to the Express Scripts Canada NIHB provider and client 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
1.6 Types of MS&E benefits
1.6.1 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 NIHB Call Centre at Express Scripts Canada 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. For instructions and forms to submit claims for reimbursement, refer to the NIHB Client Reimbursement webpage, found on the Express Scripts Canada NIHB provider and client website.
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
1.6.2 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.
Exceptions are medical supplies and equipment that are not currently listed in the NIHB Medical Supplies and Equipment Guide and 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.
Exclusions are medical supplies and equipment that are not listed in the NIHB Medical Supplies and Equipment Guide and 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)
- repair of items under warranty
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.
1.7 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.
1.8 Prescriber/recommender requirements
Prescribers who write prescriptions and recommendations must meet the following criteria:
- be a registered member of a regulatory body
- be an approved NIHB prescriber/recommender
- be operating physically in Canada at the time the prescription/recommendation is written
1.9 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 NIHB provider and client 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.
1.10 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.
1.11 Coverage of supplies, maintenance, and repairs of medical equipment covered by another benefit plan or purchased by the client
If medical equipment is funded by another benefit plan or purchased by the client, NIHB may cover associated supplies, maintenance, and/or repairs when:
- the supplies, maintenance, or repairs of the medical equipment is not covered by another benefit plan
- the medical equipment is an eligible benefit of the program
- the client qualifies for the medical equipment as per the guide and benefit lists criteria and the following requirements are satisfied:
- a prescription/recommendation for the medical equipment was obtained from a program recognized prescriber/recommender
- the medical equipment was dispensed by a provider that is recognized by the NIHB program to provide the item. This provider does not need to be enrolled in the NIHB program
- prior approval requirements and necessary information must be submitted (for example, testing/assessment information, diagnosis, device make and model, medical justification, etc.)
- additional information supporting the request (for example, equipment proof of purchase)
- the coverage of supplies, maintenance, and repairs follows the policies set out in the guide and benefit lists
1.12 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.
Rentals are used to support short term or acute conditions. When an MS&E item is rented, the rental agreement must:
- not exceed 3 months
- include the duration of the rental being requested
- indicate that rental rates are inclusive and includes:
- accessories, supplies (except where indicated in the benefits lists), all equipment maintenance, setup, education, cleaning, adjustments, replacement parts, repair, and labour
- provide the monthly rental cost
- stipulate that should the purchase of the item become an option, the amount spent on the rental will be deducted from the purchase price
Please note: reimbursement for rental equipment will not exceed the total purchase price of equivalent equipment.
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.
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
1.16 Claims submission
The NIHB program has established a price file for certain items. The prices are listed in price files, found on the Express Scripts Canada NIHB provider and client website. Please note that these prices do not apply to provider groups with whom NIHB has existing agreements.
- 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
NIHB providers must read and retain a copy of the most current version of the MS&E Claims Submission Kit located on the Express Scripts Canada NIHB provider and client website. This kit outlines provider accountability and obligations when submitting claims for payment. When an updated MS&E Claims Submission Kit is posted on the Express Scripts Canada NIHB provider and client website, there is reference to the updated kit in the Medical Supplies and Equipment Newsletter. Notification of kit updates are posted thirty (30) calendar days prior to the circulation date.
1.16.2 Client reimbursement
A client who decides to pay the full cost of an item and request a reimbursement from the program should contact the NIHB Call Centre at Express Scripts Canada or their NIHB regional office prior to purchase to confirm eligibility for item coverage and the amount covered by the program.
- To be eligible for reimbursement, the medical equipment must be eligible for coverage under the program and the client must meet program criteria for that item, as per the guide and benefit lists criteria
- prescription/recommendation must be obtained from a prescriber/recommender recognized by the program
- the medical equipment must be obtained by a provider that is recognized by the NIHB program to provide the item. This provider does not need to be enrolled in the NIHB program
- reimbursement will be provided for amounts that fall within pricing as indicated in the price files, available on the Express Scripts Canada NIHB provider and client website
- if a client is eligible for coverage by another benefit plan, only the remaining amount not covered by that plan may be reimbursed up to the program coverage
- items purchased from an online store will be considered if it meets one of the two (2) following conditions:
- the seller has a business address located in Canada, AND/OR
- the online store has a Canadian web address
- unless indicated, NIHB will only reimburse new items
The following documents must be submitted for reimbursement consideration:
- prior approval requirements including item specific information (for example, testing/assessment information, diagnosis, device make and model, medical justification from prescriber, etc.)
- original receipts are provided as proof of purchase, except in the case of coordination of benefits (COB), in this case, a copy is acceptable with a benefit statement from the other plan. The amount cannot exceed the Program unit price
Find additional information at NIHB Client Reimbursement.
1.17 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.
1.18 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 Call Centre at Express Scripts Canada or the NIHB regional office so that the client's file can be updated.
1.19 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.
1.20 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).
1.21 Privacy statement
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.
1.22 Appeal process
Clients eligible for the NIHB program have the right to appeal the denial of a benefit with the exception of items that are outside of the program mandate and/or identified as exclusions or insured services. More information is available on the Appealing a decision under the NIHB program webpage.
1.23 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 Claims Verification Program and procedures can be found in section 6 of the MS&E Claims Submission Kit, available on the Express Scripts Canada NIHB provider and client website.
1.24 Contact information
For information on billing contact the NIHB Call Centre at Express Scripts Canada.
Provider Phone Number:
Client Phone Number:
For more information on benefits and policies, contact the NIHB program at your applicable NIHB regional office.