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.

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 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:

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:

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

Medical supplies and equipment specialty qualification information form
Grouping Specialty Recognized practitioners
Audiology Audiology services and hearing devices
  • (AUD) Audiologist
  • (HIP) Hearing Instrument Practitioner or Audio-prosthetist or Hearing Aid Dispenser
Compression and burn garments Compression garment, hypertrophic scan (burn) garments, lymphedema compression devices
  • (CCGF) Certified compression garment fitter
  • (CBSGF) Certified burn scar garment fitter
Custom-made shoes and custom-made foot orthotics Custom-made shoes and custom-made foot orthotics
  • (CO(c)) Certified Orthotist by the Canadian Board for the Certification of Prosthetists and Orthotists (CBCPO)
  • (CPO(c)) Certified Prosthetist Orthotist by the CBCPO
  • (TOP) "Technicien en orthèses et prothèses" certified by the CBCPO or by "l'Ordre des technologues professionnels du Québec (OTPQ)" (Quebec only)
  • (DPM) Podiatrist (Doctor of Podiatric Medicine) registered with provincial or territorial regulatory bodies
  • (DPodM) Chiropodist registered with provincial or territorial regulatory bodies
  • (C.Ped(C)) Canadian-certified pedorthist
  • (C.Ped) Certified Pedorthist or BOC Pedorthist (BOCPD) registered with the Pedorthic Footcare Association (PFA) Canadian Chapter
Limb and body orthotics Limb and body orthotics – Class 2 (custom-fit) and Class 3 (custom-made)
  • (CO(c)) Certified Orthotist by the Canadian Board for the Certification of Prosthetists and Orthotists (CBCPO)
  • (CPO(c)) Certified Prosthetist Orthotist by the CBCPO
  • (TOP) "Technicien en orthèses et prothèses" certified by the CBCPO or by "l'Ordre des technologues professionnels du Québec (OTPQ)" (Quebec only)
  • (CHT) Registered occupational therapists and physiotherapists certified by the Hand Therapy Certification Commission, Inc. (HTCC) for upper limbs only
  • (DPM) Podiatrist (Doctor of Podiatric Medicine) registered with provincial or territorial regulatory bodies
  • (DPodM) Chiropodist registered with provincial or territorial regulatory bodies
Prosthetics Breast prostheses
  • (CMF) Certified Mastectomy Fitter
Limb prostheses
  • (CP(c)) Certified Prosthetist by the Canadian Board for the Certification of Prosthetists and Orthotists (CBCPO)
  • (CPO(c)) Certified Prosthetist Orthotist by the CBCPO
  • (TOP) "Technicien en orthèses et prothèses" certified by the CBCPO or by "l'Ordre des technologues professionnels du Québec (OTPQ)" (Quebec only)
Eye prostheses
  • (BCO) Board Certified Ocularist from the National Examining Board of Occularists (NEBO)
Oxygen Oxygen supplies and equipment
  • (RRT) Registered Respiratory Therapist
  • (RN) Registered Nurse
  • (LPN/RPN) Licensed Practical Nurse/Registered Practical Nurse when within their scope of practice in their province/territory
Respiratory supplies and equipment Respiratory supplies and equipment
  • (RRT) Registered Respiratory Therapist
  • (RN) Registered Nurse

1.5 Terms and conditions of services

Providers responsibilities:

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.

1.6.3 Exceptions

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.

1.6.4 Exclusions

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:

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:

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:

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:

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:

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

1.13 Rentals

Rentals are used to support short term or acute conditions. When an MS&E item is rented, the rental agreement must:

Please note: reimbursement for rental equipment will not exceed the total purchase price of equivalent equipment.

1.14 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.

1.15 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:

1.16 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.

Please note:

1.16.1 Provider

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.

Please note:

  • 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:

  • prescription/recommendation
  • 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:

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:

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:

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).

1.21 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.

1.22 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:
1-888-511-4666

Client Phone Number:
1-888-441-4777

For more information on benefits and policies, contact the NIHB program at your applicable NIHB regional office.

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