1.0 General policies
April 20, 2020
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 Client eligibility
- 1.3 Terms and conditions of services
- 1.4 Types of MS&E benefits
- 1.5 Prescription requirements for MS&E items
- 1.6 Prior approval process
- 1.7 Special authorization
- 1.8 Recommended replacement guidelines
- 1.9 Rentals
- 1.10 Repairs
- 1.11 Warranties
- 1.12 Claims submission
- 1.13 Coupons and promotions
- 1.14 Coordination of benefits
- 1.15 Balance billing
- 1.16 Unclaimed MS&E items
- 1.17 Privacy statement
- 1.18 Appeal process
- 1.19 Audit program
- 1.20 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 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.
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")
- 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
- an infant, less than 18 months of age, whose parent is an eligible client
- is currently registered or eligible for registration, under a provincial or territorial health insurance plan
- 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
1.3 Terms and conditions of services
- 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
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.
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.
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, 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:
- 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 licence 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. When a special authorization is provided, a prior approval number must not be included in the claim.
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.
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
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
1.12 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.
- 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 Medical Supplies and Equipment Claims Submission Kit (PDF) located on the Express Scripts Canada website. This Kit outlines provider accountability and obligations when submitting claims for payment.
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:
- 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
- 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
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 (PDF) found on the Express Scripts Canada website
1.20 Contact information
For information on billing contact Non-Insured Health Benefits Call Center at Express Scripts Canada.
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.