10.0 Low vision benefits list

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10.1 General information

10.1.1 Benefit policies

General information common to all medical supplies and equipment (MS&E) can be found in the general policies.

10.1.2 Prescriber and provider requirements

Prescriptions or recommendations for coverage must be initiated by the health professionals identified as prescribers or recommenders of the item under the NIHB program. Items that are prescribed by prescribers/recommenders not recognized by NIHB will lead to denials or reversals of claims.

NIHB recognized prescribers/recommenders include:

  • O.D. — Doctor of optometry (optometrist)
  • OMT — Certified Opthalmic Technician/Medical Technologist working under Stanton Territorial Health Authority in NWT and Nunavut
  • OT — Occupational Therapist

NIHB recognized providers include:

  • GEN — Enrolled general medical supplies and equipment or pharmacy provider

10.1.3 Prior approval requirements

General prior approval requirements can be found in the general policies.

To initiate the prior approval process, the Low Vision Prior Approval Form, found on the Express Scripts Canada website, must be completed in full and submitted to the NIHB regional office along with the following supporting documentation:

  • the prescription or recommendation or referral form signed by an NIHB recognized prescriber for the requested benefit
  • additional relevant information the provider, prescriber may have to support the request
  • an explanation of benefits from any third-party coverage available to the client (for example: provincial plan, workers' compensation board, private insurance, education plan, etc.)

10.1.4 Exclusions

General exclusions may be found under general policies.

10.1.5 Warranties

Providers must honour the manufacturer's warranty.

10.1.6 Repairs

Repairs that are not covered under the warranty are eligible for coverage when supported by proper documentation.

The following rules apply:

  • prior approval is required
  • request must include detailed cost breakdown of parts, labour time and rates
  • repairs must have a minimum warranty of 90 days

A description of all repairs with dates, detailed cost breakdown of parts, labour time and rates must be kept on file for each client.

Note: The NIHB program will not cover the labour cost for repairs that are covered under the warranty.

10.1.7 Replacement requirements

To be eligible for replacement the item must meet ONE of the following conditions:

  • be outside the recommended replacement guideline
  • not working, outside of warranty and the cost of repair exceeds the cost of a new item
  • the item no longer meets the client's needs due to a change in medical condition

All requests for replacement require a new prescription and a medical justification. If an item is required before the recommended replacement guidelines, documentation supporting the need for early replacement must be provided.

10.1.8 Services included in the price

The following services must be included in the cost of the item to be considered for coverage:

  • product and parts ordering and delivery from manufacturer to provider (including delivery costs, exchange rate)
  • dispensing of the benefit, which includes any required adjustments or fittings

10.1.9 Terminology

Item code

The item code is an 8-digit code that identifies the benefit being requested and is submitted to Express Scripts Canada for billing purposes.

Prior approval

A program coverage confirmation is issued by a FNIHB regional office to a provider to ensure that the client is eligible for specific medical supplies and equipment benefits. The approval is issued primarily for items identified as requiring prior approval before being billed to the program.

Recommended replacement guidelines

The recommended replacement guidelines set a maximum number of each item a client may receive over a given period of time (frequency). Coverage of additional items may be considered on a case-by-case basis. For requests exceeding the recommended replacement guidelines, a prior approval is required.

Maximum price

The NIHB program has established a maximum price for specific items. Maximum price information may be found on the price files located on the Express Script Canada website.

10.2 Low vision aids

10.2.1 Magnifier

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400868 Magnifier O.D., OMT, OT GEN Yes
99400869 Magnifier, illuminated head O.D., OMT, OT GEN Yes
99400870 Magnifier, illuminated handle O.D., OMT, OT GEN Yes
99400871 Microscope O.D., OMT GEN Yes
99400872 Telescope or monocular O.D., OMT GEN Yes

10.2.2 Cane

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400874 White cane O.D., OMT GEN Yes
99400875 White cane tip O.D., OMT GEN Yes 3 per year

10.2.3 Other

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400873 Coloured filters O.D., OMT GEN Yes
99400876 Face cradle, rental O.D., OMT GEN Yes covered for post-op recovery for vitrectomy surgery

10.3 Servicing

10.3.1 Delivery

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99401267 Delivery, low vision GEN Yes Delivery of equipment to client
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