This section sets out the policies and procedures for health providers on the coverage of non-insured health benefits. It contains information on Non-Insured Health Benefits (NIHB) benefit policies and lists, and references the claims processing procedures which are found on the Express Scripts Canada NIHB Claims Services Provider Web site.
In this topic...
The authority for the Non-Insured Health Benefits (NIHB) Program is based on the 1979 Indian Health Policy which describes the responsibility for the health of First Nations as shared amongst various levels of government, the private sector and First Nations communities. As a result of this shared responsibility, when a benefit is covered under another plan, the federal government requires the coordination of benefits to ensure that the other plan meets its obligations.
Health Canada's First Nations and Inuit Health Branch (FNIHB) is responsible for the policy and management of the Non-Insured Health Benefits (NIHB) Program.
Express Scripts Canada, pursuant to a contract with Public Works and Government Services, administers the Health Information and Claims Processing Services (HICPS) for dental, medical supplies and equipment (MS&E) and pharmacy benefits on behalf of the NIHB Program. That responsibility encompasses all aspects of dental, MS&E and pharmacy benefits processing and payment of claims and extends to verification, recovery, and administrative audit where deemed appropriate.
As such, Express Scripts Canada has the authority and responsibility to ensure that claims paid on behalf of Health Canada for services provided to First Nations and Inuit clients are made in accordance with the Terms and Conditions of the NIHB Program.
As a provider, it is important that you read and understand the Terms and Conditions of the Program described in the Claims Submission Kits (www.provider.esicanada.ca). The submission of a claim by you indicates your understanding and acceptance of the Terms and Conditions of the NIHB Program. Provider non-compliance with these Terms and Conditions may result in suspension or removal of your billing privileges under the NIHB Program as well as any recovery mechanisms that may be required.
Program policy and claim submission/payment information will be made available to providers through:
It is important that providers retain the most current documentation to ensure program requirements are met.
Note to Dental Providers only - Use of treatment codes and standard definitions based on the Canadian Dental Association's Uniform system of Coding and list of services.
For further information please visit the Express Scripts Canada Non-Insured Health Benefits Claims Services Provider Web site (www.provider.esicanada.ca).
The Non-Insured Health Benefits (NIHB) Program of Health Canada recognizes an individual's right to control who has access to his or her personal information and the purpose for which that information will be used. The NIHB Program is committed to protecting an individual's privacy and safeguarding the personal information in its possession.
When a request for benefits is received, the NIHB Program collects, uses, discloses and retains an individual's personal information according to the applicable privacy legislation. The information collected is limited only to information needed for the NIHB Program to provide and verify benefits and to ensure that claims paid on behalf of Health Canada for services provided to First Nations and Inuit clients are in accordance with the terms and conditions of the NIHB Program.
As a program of the federal government, the NIHB Program must comply with the Privacy Act, the Canadian Charter of Rights and Freedoms, the Access to Information Act, Treasury Board policies and guidelines including, the Treasury Board of Canada Government Security Policy, and the Health Canada Security Policy. The NIHB Privacy Code addresses the requirements of these acts and policies.
Objectives of the NIHB Privacy Code:
The Non-Insured Health Benefits Privacy Code is based on the ten principles set out in the Canadian Standards Association, Model for the Protection of Personal Information (The CSA Model Code) which is also schedule 1 to the Personal Information Protection and Electronic Documents Act (PIPEDA), commonly regarded as the national privacy standard for Canada.
Providers wishing to provide services to NIHB clients must register/enroll with Express Scripts Canada. For additional information please consult the Express Scripts Canada Non-Insured Health Benefits Claims Services Provider Web site (www.provider.esicanada.ca) or call the Express Scripts Canada Provider Claims Processing Call Centre at 1-888-511-4666.
All applications for registration as an NIHB provider are subject to review by the program. NIHB Provider numbers are processed based on the administrative needs of the NIHB Program.
The procedures for submitting an NIHB claim are outlined in the Claims Submission Kits found on the Express Scripts Canada Non-Insured Health Benefits Claims Services Provider Web site (www.provider.esicanada.ca). The site also contains claim forms, newsletters, dental fee schedules and much more.
Note: NIHB dental providers are 100% financially responsible for all services paid under their provider number(s) regardless of being an associate or owner and/or owner partner (primary) in the clinic.
Health Canada's Non-Insured Health Benefits (NIHB) Program and policies information are outlined in the following provider specific guides:
Supplementing the information found in the Claims Submission Kits, these guides explain the extent and limitation of the NIHB Program for each benefit by describing the important elements of each associated benefit policy.