11.0 Mobility equipment and supplies benefits list

11.1.1 Benefit policies

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

11.1.2 Prescriber and provider requirements

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

The following is a list of NIHB recognized prescriber/recommender abbreviations found in this segment of the benefits list. Please refer to the prescriber section of the item tables below to identify the eligible prescriber/recommender of a specific item:

• LPN/RPN — Licensed Practical Nurse/Registered Practical Nurse when within their scope of practice in their province/territory (see endnote ^{Footnote 1} and ^{Footnote 2})
• MD — Physician
• NP — Nurse Practitioner
• OT — Occupational Therapist
• PT — Physiotherapist
• RN — Registered Nurse

The following is a list of NIHB recognized provider abbreviations found in this segment of the benefits list. Please refer to the provider section of the item tables below to identify the eligible provider of a specific item:

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

11.1.3 Prior approval requirements

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

To initiate the prior approval process, the Mobility Prior Approval Form, found on the Express Scripts Canada NIHB provider and client website, must be completed in full and submitted to your 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
• detailed assessment (see appropriate section), including whether specialized equipment (standing frames, walkers, wheelchairs, strollers) has been trialed
• additional relevant information the provider, physician, nurse practitioner, occupational therapist, or physiotherapist 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.)

11.1.4 Exclusions

In addition to the general exclusion policy listed in the general policies, the following items are excluded from the mobility benefit and are not considered for coverage or appeal under the NIHB program:

• equipment with a rated capacity that would be unable to bear the client's weight
• scooters

11.1.5 Warranties

• providers must honour the manufacturer's warranty
• all wheelchairs and medical strollers must carry at a minimum, a one-year warranty

11.1.6 Repairs

The program will cover minor repairs to wheelchair under a special authorization process. When providers submit a prior approval for a new wheelchair or request a repair to an existing wheelchair, a special authorization will be created to allow the provider to directly claim up to the unit price established in the price file for subsequent repairs. The special authorization will be effective from the device warranty expiration date to the device frequency limit. Repairs prices include parts (the program only covers new parts) and labour.

Prior to performing a repair, the provider must communicate with Express Scripts Canada to confirm if prior approval is required. 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 for repairs exceeding the unit price or frequency
• 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.

11.1.7 Replacement requirements

Recommended replacement guidelines indicate the quantity and frequency at which a benefit item will be eligible for coverage. Recommended replacement guidelines are based on a client's customary medical needs and the typical device's lifespan.

Replacement is subject to the same process as the original purchase.

All requests for replacement require a new prescription.

For more general information please see section 1.12 Recommended replacement guidelines.

11.1.8 Services included in the price

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

• initial assessment to determine the type of benefit required
• product and parts ordering and delivery from manufacturer to provider (including delivery costs, exchange rate)
• adjustments or fittings
• dispensing of the benefit

11.1.9 Terminology

11.2.1 Positioning seat

11.3.1 Frame

11.4.1 Cane

11.4.2 Crutches

11.4.3 Walker

11.6.1 Manual wheelchair

11.6.2 Power wheelchair

Eligibility criteria in addition to general wheelchair eligibility:

• the client or caregiver must be able to care for a power wheelchair and keep batteries charged
• the client must be able to safely, independently and with good judgment operate a power wheelchair
• the wheelchair is the client's primary mobility device
• the wheelchair is needed for indoor use to meet client's need for activities of daily living

11.7.1 Back support

11.7.2 Seat cushion

11.7.3 Arm rest

11.7.4 Calf

11.7.5 Caster

11.7.6 Head-neck rest

11.7.7 Foot

11.7.8 Stabilizer

11.7.9 Interface mounting

11.7.10 Pommel

11.7.11 Positioning

11.7.12 Tray

11.7.13 Other wheelchair parts

11.9.1 Repairs

11.9.2 Delivery

11.9.3 Labour