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Provider Guide for Medical Supplies and Equipment (MS&E) Benefits

The procedures for submitting a Non-Insured Health Benefits (NIHB) Medical Supplies and Equipment claim are outlined in the Medical Supplies & Equipment (MS&E) Claims Submission Kit found on the ESI Canada's NIHB MS&E Claim Services Provider Web site: www.provider.esicanada.ca. Providers are reminded to use their individual User ID and Password to access ESI Canada's Web site.

Help on accessing alternative formats, such as Portable Document Format (PDF), Microsoft Word and PowerPoint (PPT) files, can be obtained in the alternate format help section.

(PDF Version - 157 K)

This guide provides information on the Health Canada Non-Insured Health Benefits (NIHB) Program and policies relevant to medical supplies and equipment (MS&E) providers. It explains the extent and limitations of the NIHB Program's MS&E benefits by describing the important elements of each associated policy. It also lists website addresses to give providers quick access to related forms and more detailed Program information.

The guide is intended to supplement the information contained in the Medical Supplies and Equipment (MS&E) Claims Submission Kit, which explains the MS&E provider process for submitting claims for payment of goods rendered to eligible Clients.

1.0 Introduction
2.0 Medical Supplies and Equipment (MS&E) General Policies
3.0 Benefit Description and Conditions
4.0 Payment and Reimbursement
5.0 Appendices

1.0 Introduction

Health Canada's Non-Insured Health Benefits (NIHB) Program provides a limited range of medically necessary health-related goods and services to eligible registered First Nations and recognized Inuit, when these goods and services are not already provided through private insurance plans, provincial or territorial health and social programs, or other publicly funded programs.

NIHB Program benefits include a specified range of medical supplies and equipment; prescription drugs and over-the-counter medications; dental and vision care; short-term crisis mental health counselling; and transportation to access medically required health services that are not available on the reserve or in the community of residence. The Program also funds provincial health premiums for eligible Clients in British Columbia.

The Provider Guide for Medical Supplies and Equipment (MS&E) Benefits explains the terms and conditions, the policies, and the benefits under which the NIHB Program will reimburse medical supplies and equipment provided to eligible Clients.

As policies and procedures evolve, the guide is updated accordingly and providers are advised of these changes through the Program's newsletters and bulletins.

Providers are advised to read and retain the most current version of the guide to ensure continued compliance with their NIHB provider agreement. In the event of contradiction between document versions, the provisions of the Health Canada web-posted guide will prevail.

Quick Links

Annual Report 2007/2008
Medical Supplies and Equipment (MS&E) Bulletins
Newsletters for Medical Supplies and Equipment (MS&E) Providers
Oxygen Benefits Notices to Providers
RSS (really simple syndication) Feeds

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2.0 MS&E General Policies

The following policies impact the benefits under which the NIHB Program will reimburse claims for medical supplies and equipment provided to eligible Clients.

Please note that all equipment and many supplies require prior approval for reimbursement. It is imperative that items requiring prior approval are not dispensed before approval is granted by the appropriate Health Canada Regional Office to avoid delays and ensure claims are reimbursed. See Section 2.4: Prior Approval for additional details.

2.1 Exceptions

Exceptions are items that are not listed on the MS&E benefit list, but which may be considered on a case-by-case basis with written medical justification and prior approval. MS&E providers should refer to the prior approval section of this guide and follow its procedures to proceed with 'exceptions'.

2.2. Exclusions

Exclusions are items that are not listed on the MS&E benefit list and do not apply to the exception process. These items are not considered for coverage under the NIHB Program and cannot be appealed.

2.3 Quantity Limitations

Items that have an annual quantity limitation must be provided and billed for no more than a three-month period at a time. This applies to items with or without prior approval.

2.4 Prior Approval Requirements

Some items not listed on NIHB MS&E benefit list may be considered for NIHB Program coverage under special circumstances, with prior approval.

To request prior approval, the MS&E provider must:

obtain from the Client, the written prescription issued by a physician or nurse practitioner (further details provided in the sub-benefit sections of this Guide);
obtain Client identification information;
contact the appropriate Health Canada Regional Office to initiate the prior approval process before dispensing the item;
give the precise date of service (for one time item), or the dates of the service period (for multiple dispenses), to the benefit analyst of the Health Canada Regional Office; and,
when required, complete and submit the appropriate prior approval form to the Health Canada Regional Office.

Note: NIHB reserves the right to request additional information if deemed necessary.

Prior approvals may also be generated automatically by the electronic claims adjudication system when a claim is submitted electronically. The claim may be rejected if the criteria for automated prior approval have not been met. If rejected, the provider may resubmit the claim through the system to have the prior approval reviewed by the appropriate Health Canada Regional Office. Providers should be aware that a representative of the Regional Office may call them directly to discuss the request or to collect any necessary information.

If prior approval is granted, a confirmation letter with the applicable dates and prior approval details may be faxed, mailed, or e-mailed to the provider. Only then should the provider proceed with the fabrication, fitting, or dispensing of the item. If prior approval is not granted, the provider will be advised of the reason.

Prior approvals are entered electronically on the claims processing system. The date of dispense should be indicated on the electronic claim form or to the analyst so it can be reflected in the prior approval. MS&E providers are advised to retain the confirmation letter, if applicable, for billing purposes and/or to validate any discrepancies. When submitting the claim, providers must be sure to include the date of service (dispense date).

2.5 Recommended Replacement Guidelines

Equipment, devices and supplies are provided to meet the medical needs of Clients. Guidelines outlining recommended quantities or replacements are based on the average medical needs of Clients. For individual items, refer to the recommended replacement guidelines in the benefit list. Requests exceeding these guidelines may be considered on a case-by-case basis, if a need is demonstrated.

Early replacement of equipment and devices will be considered only when a substantial change in the condition of the Client results in changed needs or if the equipment or device has deteriorated during the course of normal use and cannot be economically repaired. Where a change in the medical condition has occurred, medical information documenting the change in needs must be provided.

Replacements will not be provided as a result of misuse, carelessness or Client negligence.

2.6 Coupons and Promotions

When accessing benefits through the NIHB Program, eligible Clients may not directly or indirectly benefit from special promotions or incentives, including coupons, discounts, points or rebates in the form of cash and/or goods that may be offered by providers. To the extent permitted by such promotions and applicable law, the coupons, discounts or rebates should be applied to the NIHB claim. As a result, the amount claimed through the NIHB Program must be the residual amount after application of the promotion.

2.7 Rentals

When an MS&E item is rented, the rental agreement must include maintenance and repair costs because the NIHB Program does not pay for the maintenance or repairs of rental equipment. The rental agreement must also include a clause stipulating that should the purchase of the item become an option, the amount spent on the rental will be considered when the purchase price is set.

2.8 Repairs

Only the most recently purchased item qualifies for maintenance and repairs under the NIHB Program. Repairs must restore the item to physical condition allowing for normal wear and tear, and have a warranty according to industry standard. Once the warranty is expired, prior approval is required for all repairs and, if more cost effective, the item should be replaced instead of repaired. Note that a prescription is not needed for repairs.

2.9 General Warranties

All warranty coverage must be exhausted before requests for the payment of repairs are submitted to the NIHB Program. When MS&E items have warranty coverage, as a minimum, the warranty must specify that during the warranty period:

the provider will provide or cause to be provided any service including repairs or replacements of the item device or any components free of charge;
repairs and services are the responsibility of the vendor, manufacturer or service designate; and,
where there is repeated technical failure, the device will be replaced by the provider at no cost to the NIHB Program.

MS&E providers should be aware that they 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.

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3.0 Benefit Description and Conditions

The medical supplies and equipment component of the NIHB Program covers items that are: included on the NIHB MS&E benefit list; prescribed by a health professional licensed to prescribe in a given provincial jurisdiction, such as a physician; and provided by a supplier who is eligible to provide the specific MS&E item.

MS&E benefits are based on policies established by Health Canada to provide eligible Clients with access to benefits not otherwise available under federal, provincial, territorial or private health insurance plans. This includes 'open benefits' which are listed on the NIHB MS&E benefit list and do not require prior approval, and 'limited use benefits' which may have an annual quantity limitation or require prior approval.

MS&E benefits are covered in accordance with the mandate of the NIHB Program. NIHB Clients do not pay deductibles or co payments.

MS&E Benefit List

Health Canada maintains an up-to-date list of medical supplies and equipment which are eligible NIHB benefits. Items on the MS&E benefit list are primarily used in a home or ambulatory setting. They have been included on the list based on the judgement of recognized health professionals, consistent with the best practices of health services delivery and evidence-based standards of care.

The MS&E benefit list comprises seven benefits including: general MS&E; audiology; orthotics and custom footwear; oxygen equipment and supplies; pressure garments and pressure orthotics; prosthetics; and respiratory equipment and supplies. Providers should regularly review these lists to ensure that they continue to be aware of the MS&E benefits included in the NIHB Program.

Quick Link

Non-Insured Health Benefits (NIHB) Medical Supplies and Equipment (MS&E) Benefit List (A to Z list)

3.1 General MS&E Benefits

3.1.1 General MS&E Benefit Categories

The general benefit categories are:

bathing and toileting aids;
protectors;
dressing aids;
feeding aids;
miscellaneous supplies and equipment;
lifting and transfer aids;
mobility aids, such as walking aids, walking aids accessories, wheelchairs, wheelchair cushions and wheelchair parts;
ostomy supplies and devices;
catheter supplies and equipment;
incontinence supplies and equipment, such as diapers and catheters; and,
wound dressing supplies, such as adhesive tapes and dressing strips, bandages, dressings, and other dressings.

3.1.2 Prescriber/Provider Requirements

General MS&E benefits must be prescribed by a physician or nurse practitioner, and provided by a recognized NIHB pharmacy or recognized NIHB MS&E provider.

3.1.3 Prior Approval Process

For items requiring prior approval, the provider must contact the Health Canada Regional Office to initiate the process. For a list of these items, refer to the general MS&E benefit list.

The NIHB General MS&E Prior Approval Form must be completed. In addition to the form, the following documentation is required to support the request:

the prescription and any other information the provider/prescriber may have to support the request;
a copy of any third-party coverage (e.g., workers' compensation board, private insurance, etc.); and,
the medical guidelines and required information for authorizing general MS&E benefits as described in the MS&E policies section 3.1.4 of this guide.

Quick Link

General Medical Supplies and Equipment (MS&E) Prior Approval Form

3.1.4 General MS&E Benefit Policies

A. Medical Guidelines and Required Information

The Health Canada Regional Office adheres to the following medical guidelines when authorizing certain medical supplies and equipment. They also require specific information from MS&E providers to proceed with such authorizations.

a) Bath chair lift (water powered)

An occupational therapy/physiotherapy (OT/PT) report is required summarizing the Client's medical, physical, and/or functional status, such as the Client's mobility and transfer status. The report must also explain why a transfer bench with a hand-held shower will not meet the Client's need.

b) Breast pumps

Breast pumps may only be approved when the mother presents medical physical complications hindering the normal physiological process of breast feeding. Providers are required to report on the mother's condition.

c) Catheter supplies and equipment

Providers are required to give the Client's diagnosis and justification for the use of catheter supplies and equipment. For frequency replacement, consult the general MS&E benefit grid.

d) Dressings requiring prior approval

Providers are required to give the Health Canada Regional Office the Client's diagnosis; a wound/ulcer assessment from a nurse, a physician or an occupational therapist, including the number of wounds; the size, the site, the type of exudates; the frequency of dressing change; and all other pertinent information regarding the wounds.

e) Feeding pump

Feeding pumps may be approved if a Client cannot receive feeding through gravity.

f) Incontinence supplies

Disposable diapers and pull-up briefs
NIHB will provide a total of four to six incontinence supplies per day (i.e., five diapers or a combination of two different products for a total of six items.) Providers are required to give the following information to the appropriate Health Canada Regional Office:

the medical diagnosis of the cause(s) for the incontinence;
the type of incontinence (urine/stools or both);
when the incontinence occurs (day/night or both);
the type of incontinence supplies needed;
the amount of incontinence supplies needed; and
all other pertinent information.

Pant (brief) mesh
NIHB recommends three per month for Clients who have no other means to secure in place the incontinence supplies. These pants are washable.

Disposable Underpads
NIHB recommends a maximum 50 disposable underpads per month for Clients doing regular bowel care routine.

Reusable Underpads
NIHB recommends two reusable underpads that are used to protect the mattresses of incontinent Clients with the initial request and one per year afterward.

g) Lift, hydraulic (powered)

An OT/PT report is required summarizing the Client's medical, physical, and/or functional status, such as the Client's mobility and transfer status. The report must also explain why a standard hydraulic lift will not meet the Client's need.

h) Manual wheelchairs

NIHB funds one mobility device every five years (e.g., the Client's primary mobility device). An above-the-knee or below-the-knee amputee qualifies for a manual wheelchair. An OT/PT report is required summarizing the Client's medical, physical, and/or functional status, such as the Client's mobility and transfer status. The report must also explain why this particular wheelchair is the only device that will meet the Client's need. Rental requests are assessed on a case-by-case basis.

B. Exclusions

Exclusions are items which will not be provided as benefits under the NIHB Program under any circumstances. For general MS&E benefits, exclusions include but are not limited to:

scooters (considered a mode of transportation for outdoor use only);
hospital beds, mattresses and bedding (considered household items and beyond the scope of NIHB Program. Costs for household items are the responsibility of the Client);
permanently fixed equipment (e.g., grab bars, ceiling tracks for lifts, stair lifts, etc. that are fixed to a wall/ceiling);
lift chairs (considered household furniture. Costs for household items are the responsibility of the Client);
pressure relief mattresses and alternating air pressure overlay pads powered or non-powered (which are beyond the scope of NIHB Program); and
environmental protection devices and supplies (e.g., masks, air cleaners, filters, UV protection garments and lotions, etc. which are beyond the scope of NIHB Program).

3.1.5 General MS&E Benefit Grid

The General Medical Supplies and Equipment (MS&E) Benefit List is available on the Health Canada website.

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3.2 Audiology Benefits

3.2.1 Audiology Benefit Categories

The audiology benefit categories are:

hearing aid, bone conduction hearing aid, conventional analog;
hearing aid, CROS/BiCROSS;
hearing aid, Programmable Analog;
hearing aid, digital entry level;
hearing aid services, fees, repairs and supplies; and,
hearing aid pricing.

3.2.2 Prescriber/Provider Requirements

Audiology benefits must be prescribed by a physician or nurse practitioner, and provided by a recognized NIHB audiologist or recognized NIHB hearing aid dispenser. Batteries may be provided by a recognized NIHB audiologist, hearing aid specialist, other medical supply and equipment provider, or a pharmacist. In British Columbia, providers are to continue to follow the procedures outlined in the hearing aid program put in place by the NIHB British Columbia Regional Office.

A medical prescription is required to rule out medical conditions other than hearing loss and to support the need for assessment by an audiologist or other hearing aid specialist. The audiologist or other hearing aid specialist will determine the type of device required to meet Client's needs.

3.2.3 Prior Approval Process

With the exception of batteries, all audiology benefits require prior approval. This includes both new and replacement hearing aids. To initiate the prior approval process, the provider must contact the appropriate Health Canada Regional Office.

The NIHB Hearing Aid and Hearing Aid Repair Prior Approval Form must be completed. In addition to the form, the following documentation is required to support the request:

the prescription;
the most recent audiometric test (six months or less);
the current hearing aid information (in case of a replacement aid);
in the case of repairs (manufacturer name, model number or name, date fitted, and serial number);
any other information the provider/physician or nurse practitioner may have to support the request;
a copy of any third-party coverage (e.g., workers' compensation board, private insurance, etc.); and,
the medical guidelines and required information for authorizing audiology benefits as described in the audiology policies section 3.2.4 of this guide.

Once the provider has dispensed or repaired the hearing aid, the NIHB Hearing Aid and Hearing Aid Repair Confirmation Form must be completed, signed and returned to the Regional Office. The provider's signature is required to confirm that the Client has received and is satisfied with the equipment or repair and instruction provided. A copy of the completed and signed form should be retained by the provider for audit purposes.

Quick Link

Hearing Aid and Hearing Aid Repair Prior Approval Form

3.2.4 Audiology Benefit Policies

A. Medical Guidelines and Required Information

The Health Canada Regional Office adheres to the following medical guidelines when authorizing certain audiology benefits. They also require specific information from MS&E providers to proceed with such authorizations.

a) Hearing aids and/or replacement of hearing aids

Providers will be required to provide a recent audiogram (less than six months); the manufacturer's name; the model and size of the requested aid; and previous NIHB funding and repairs.

b) Replacement Ear Mould

Providers will be required to use specific benefit codes and to provide complete information about the previous NIHB funding and repairs. When an initial 'behind the ear' hearing aid is dispensed, the price of the mold (although requested separately on the prior approval form) must be included in the price of the hearing aid. In these cases, no benefit code is to be used.

B. Exclusions

Items excluded from the audiology benefit list do not apply to the exception process, are not considered for coverage under the NIHB Program, and cannot be appealed. These include:

items used for education/school such as FM equipment and assistive listening devices;
surgical implants;
assistive speech devices used to communicate and/or replace a person's voice;
noise breakers used for specific tasks in work-related situations; and,
therapy treatment, such as speech therapy.

C. Follow up

After the Client has had an opportunity to gain some experience using their device(s), further evaluation and appropriate action needs to be taken by the provider. This includes:

appropriate reinforcement of information, instructions, and retraining on the device, if necessary*;
any modifications to improve the comfort of the device;
any modifications to the electroacoustic characteristics of the device based upon reactions and experiences of the Client;
further advice or reinforcement regarding user operation;
Client reactions to amplification and any adjustments or changes that need to be made to enhance Client benefit from the device;
indication of the benefits perceived by the Client; and,
any further action that is required.

*Note that any problems with hearing aid usage and/or tolerance noted by the Client to the provider should be identified and action taken.

Follow-up after warranty has expired
After-care services are services which take place after the dispensing fee services under the manufacturer's warranty have expired (usually a minimum of two years) or services not covered by the manufacturer's warranty. Most after-care services will involve repairs or replacement of earmoulds such as:

Adjustments to the client's fitting, including an earmould which may be necessary from time to time and that is undertaken as part of the general after-care services. These adjustments may be invoiced according to the fee schedule.
The Client may require advice, outside a formal appointment, regarding their fitting or their hearing loss. This must be accommodated by the clinic and/or service provider.

D. Repairs

Repairs must result in restoring the hearing aid to the original performance level. While a physician or nurse practitioner prescription is not needed for repairs, prior approval must be obtained for all billable hearing aid repairs.

Out-of-office and in-office hearing aid repairs are not subject to service fees while the aid is in warranty by the manufacturer unless the out-of-office repair incurs a charge which is not covered by the warranty.

Out-of-office hearing aid repairs which incur a charge by the manufacturer (after the original manufacturer's warranty has expired) should include a warranty unless the cost of replacement is more economical. In-office hearing aid repairs do not have a warranty.

Repair warranty periods

Repair warranty periods must be consistent with the current Canadian Auditory Equipment Association-NIHB agreement:

Repairs carried out on a hearing aid during the product purchase warranty period are guaranteed for a maximum of 12 months after repair or until the original product warranty expires, whichever comes first.
All repairs and remakes carried out on a hearing aid after the warranty period expires will be subject to a maximum cost outlined in the pricing grid and will carry a 12-month warranty if the hearing device is less than five years old.
Charges for repairs and remakes can only be billed after the warranty period, two calendar years for new aids and one calendar year after the repair or remake of an aid.
A remake includes the provision of a new shell for the aid and replacement of required existing electronic components to ensure that the aid has been returned to the equivalent operating standard of a new aid.

Timeline

It is desirable that repairs be made at the time the Client presents with the problem. If same day repair cannot be done, a loan hearing aid should be provided if desired by the Client. A Behind The Ear (BTE) type hearing aid is acceptable as a loan hearing aid for In The Ear (ITE) and In The Canal (ITC) hearing aids. If the hearing aid is not repaired at the service point and needs to be sent to another point to be repaired, it should be returned to the Client as soon as possible. Batteries and repair services must be available at each permanent site during regular business hours. There should be at least one permanent site for a provider.

E. Warranties

All hearing instruments and/or devices will carry, at a minimum, a two-year warranty and one-year 'loss and damage replacement' coverage for one occurrence per aid. Hearing instruments and/or devices provided to children under 16 years of age will have a two-year 'loss and damage replacement' coverage, applicable to only one occurrence per aid. Warranties that go beyond these provisions will extend the same benefits to NIHB Clients. All items will have a 90-day return privilege at no cost to the hearing aid dispenser.

3.2.5 Audiology Benefit Grid

The Audiology Benefit Grid is available on the Health Canada website.

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3.3 Orthotics and Custom Footwear Benefits

3.3.1 Orthotics and Custom Footwear Benefit Categories

The orthotics and custom-made footwear benefit list covers the following items:

Orthotics:

limb orthoses for lower and/or upper extremities;
head, torso and/or spine orthoses;
orthotic supplies; and,
custom-made internal footwear devices (foot orthoses).

Custom-made footwear:

custom-made shoes; and,
modifications to stock footwear.

3.3.2 Prescriber/Provider Requirements

Limb and body orthotic devices must be prescribed by:

a physician or nurse practitioner for class I (soft); or,
a specialist in the field of physiatry, orthopedics, plastic surgery, neurology, rheumatology, pediatrics, geriatrics, or general surgery for class II (rigid) and class III (custom-made) items.

While it is recognized that access to a medical specialist may be an issue in some areas, a prescription from a specialist is required for the first issue of a Class II (rigid) and Class III limb or body orthotic device. A prescription from a general practitioner or nurse practitioner will be accepted for replacement of the same type of body or limb orthotic device.

Limb and body orthotic devices must be provided by:

a certified orthotist (CO(c)) or certified prosthetist orthotist (CPO(c)), as certified by the Canadian Board for the Certification of Prosthetists and Orthotists (CBCPO) or a recognized NIHB pharmacist or recognized NIHB MS&E provider for class I (soft); or,
a CO(c) or CPO(c), as certified by the CBCPO for class II (rigid) and class III (custom-made) items

Note: foam cervical collars, abdominal supports, hernia trusses and sacral or lumbosacral supports, cloth or elastic braces with or without steel stays can be provided by pharmacy and MS&E providers.

Custom-made shoes, custom made internal footwear devices (orthotics) or modifications to stock footwear must be prescribed by:

a specialist in the field of physiatry, orthopedics, plastic surgery, neurology, rheumatology, pediatrics, geriatrics, oncology, general surgery or infectious diseases for custom-made shoes; or,
a physician or nurse practitioner for custom-made internal footwear devices (foot orthotics) and modifications to stock footwear.

While it is recognized that access to a medical specialist may be an issue in some areas, a prescription from a specialist is still required for the first issue of custom-made shoes. A prescription from a general practitioner or nurse practitioner will be accepted for replacement of custom-made shoes.

Custom-made shoes, custom-made internal footwear devices (orthotics) or modifications to stock footwear must be provided by:

a Canadian-CO(c), Canadian-CPO(c), podiatrist (chiropodist or DPodM ) registered with provincial / territorial regulatory bodies, doctor of podiatric medicine (DPM) registered with provincial or territorial regulatory bodies, or Canadian-certified pedorthist (Cped(c)) for custom-made internal footwear devices (orthotics).

3.3.3 Prior Approval Process

Prior approval is required for all orthotic devices, custom-made internal footwear devices, custom-made shoes, or modifications to stock footwear. To initiate the prior approval process, the provider must contact the appropriate Health Canada Regional Office.

The NIHB Orthotics-Custom Shoes-Prosthetics-Pressure Garments Prior Approval Form must be completed. In addition to the form, the following documentation is required to support the request:

the prescription;
detailed assessment from the provider, including requirements for custom-made shoes and custom-made internal footwear devices as specified in section 3.3.4 of this guide;
any other information the provider/physician or nurse practitioner may have to support the request;
a copy of any third-party coverage (e.g., workers' compensation board, private insurance, etc.); and,
the medical guidelines and required information for authorizing orthotics and custom-made shoes as described in section 3.3.4.

Quick Link

Orthotics-Custom Shoes-Prosthetics-Pressure Garments Prior Approval Form

3.3.4 Orthotics and Custom Footwear Benefit Policies

A. Medical Guidelines and Required Information

The Health Canada Regional Office adheres to the following medical guidelines when authorizing certain orthotics and custom footwear benefits. They also require specific information from MS&E providers to proceed with such authorizations.

a) Custom thoracolumbarsacral

Because orthotics for spinal fractures often need to be fitted while the Client is in an acute hospital, providers are required to give the Regional Office the diagnosis, date of fracture, and the date of surgery, if applicable.

b) Custom-made shoes

Providers are required to give the Regional Office:

measurements of the feet;
templates/drawing/tracing of the contour of the feet and/or (preferred) photographs of the feet;
the prescriber's speciality;
the provider's qualification;
the diagnosis and Client's biomechanical/medical assessment (i.e., significant deformities of the feet);
the casting technique (plaster of Paris slipper cast);
manufacturing technique, material used, and design of shoes;
name of the laboratory; and,
warranty details.

c) Custom-made internal footwear device (foot orthoses)

Providers are required to give the Regional Office:

the diagnosis and Client's symptoms (e.g., heel pain, metatarsalgia, tendinitis, etc.);
biomechanical/medical assessment (e.g., pronation, pes planus/flat feet, bunions, claw toes, etc.);
type of device (e.g., accommodative or functional);
casting technique (for accommodative devices, the NIHB accepted casting techniques are plaster of Paris slipper cast, foam box and contact digitizing (Amfit) and for functional devices, plaster of Paris slipper cast and contact digitizing (Amfit) only);
manufacturing technique and material used;
name of the laboratory; and,
warranty details.

B. Exclusions

Items excluded from the orthotics and custom footwear benefit list do not apply to the exception process, are not considered for coverage under the NIHB Program, and cannot be appealed. These items include:

foot products manufactured only from laser or optical scanning or computerized gait and pressure analysis systems;
pre-fabricated foot orthotics and internal footwear devices;
therapy treatment and/or therapy equipment such as but not limited to:
- electrospinal orthesis;
- transcutaneous/neuromuscular;
- neurostimulators;
- direct passive movement devices;
- electromagnetic stimulators for osseous growth; and,
- therapy, including physiotherapy.
off-the-shelf therapeutic and orthopaedic footwear (e.g., pair of shoes, running shoes, boots, summer sandals, etc.).

C. Services included in price

The following services are to be included in the price of the benefit:

initial assessment to determine the type of benefit required;
casting of the body part for the manufacturing of the device;
manufacturing of device;
dispensing of the benefit, which includes the adjustment, fitting; and,
follow-up visit(s).

D. Warranty

The manufacturer/provider warranty will include:

No charge for necessary adjustments to the custom-made internal footwear device (custom-made foot orthotics) for a period of three months after the final fitting, except when there has been a change in the Client's medical condition which would prevent a satisfactory fit.
Breakage guarantee for six months and no charge for necessary adjustments to a custom-made orthoses (limb and body) for a period of three months after the final fitting except when there has been a change in the Client's medical condition which would prevent a satisfactory fit.
Breakage guarantee for two months and no charge for necessary adjustments to a customized orthoses/pre-fabricated (limb and body) for a period of 30 days after the final fitting except when there has been a change in the Client's medical condition which would prevent a satisfactory fit.
No charge for repairs to custom-made shoes for one year period.

3.3.5 Orthotics and Custom Footwear Benefit Grid

The Orthotics and Custom Footwear Benefit Grid is available on the Health Canada website.

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3.4 Oxygen Equipment and Supplies Benefits

3.4.1 Oxygen Equipment and Supplies Benefit Categories

The oxygen equipment and supplies benefit categories are divided into oxygen systems and equipment, and oxygen supplies.

3.4.2 Prescriber/Provider Requirements

Home oxygen must be prescribed by a physician. Home oxygen equipment and supplies must be prescribed by a physician or nurse practitioner, and provided by an NIHB-recognized oxygen provider with appropriate health care staff with regulatory affiliations (i.e., registered respiratory therapist/registered nurse familiar with respiratory conditions).

Providers should be aware that their Client's condition must be stabilized and the treatment regimen optimized before home oxygen may be considered by the NIHB Program.

3.4.3 Prior Approval Process

Prior approval is required for all home oxygen equipment and supplies benefits. To initiate the prior approval process, the provider must contact the appropriate Health Canada Regional Office.

The NIHB Home Oxygen and Respiratory Equipment and Supplies Benefits Approval Form must be completed with the Client's address. In addition to the form, the following documentation is required to support the request:

the prescription stating the oxygen flow (litres per minute) and numbers of hours per day;
indicate if the request is for a new application or a renewal for home oxygen;
the expected dates of service (i.e., May 01, 2009 to July 31, 2009);
any other information the provider/physician or nurse practitioner may have to support the request;
a copy of any third-party coverage (e.g., workers' compensation board, private insurance, etc.); and,
the medical guidelines and required information when authorizing certain oxygen equipment and supplies benefits as described in section 3.4.4.

Quick Link

Home Oxygen and Respiratory Equipment and Supplies Benefits Approval Form

3.4.4 Oxygen Equipment and Supplies Benefit Policies

A. Medical Guidelines and Required information

The Health Canada Regional Office adheres to the following medical guidelines when authorizing certain oxygen equipment and supplies benefits. They also require specific information from MS&E providers to proceed with such authorizations.

a) Concentrators/homefill, initial request (three month approval only)

Home oxygen may be considered for NIHB coverage once the Client's condition is stabilized. To be considered, test results must be obtained when Client's condition has stabilized. Arterial blood gas (ABG) results obtained during an acute exacerbation are not acceptable. If ABG is not available, refer to section c) and d) below.

Qualifying medical indications for home oxygen include:

a resting PaO2 on room air equal or less than 55 mm Hg;
a resting PaO2 on room air between 56 and 59 mm Hg when there is supporting document evidence provided by a physician and ABG of cor pulmonale, pulmonary hypertension and/or secondary polycythemia;
- persistent PaO2 between 56 and 59 mm Hg, when there is evidence of:
- exercise limitation due to hypoxemia with significantly greater exercise capability and/or significantly decreased shortness of breath on oxygen compared to room air (ABG and a walking oximetry is needed) and/or
- nocturnal hypoxemia when nocturnal oxygen desaturation is less than 88% for 30% of the night and sleep disordered breathing is ruled out (ABG and a nocturnal oximetry is needed);
New York Heart Association Stage IV Heart Disease with supporting documented evidence provided by a cardiologist and ABG; and
palliative care (less than three months life expectancy) for Clients demonstrating persistent hypoxemia:
- PaO2 on room air ≤60mmHG;
- O2 saturation ≤92% demonstrated by a resting oximetry; and/or,
- dyspnea that cannot be improved with medication and/or comfort analgesia (ABG or a resting oximetry is needed along with a clear diagnosis supporting the end stage of palliative condition by a physician, nurse practitioner or palliative care member to document noting that the dyspnea cannot be improved with medication and/or noting that comfort analgesia are needed.

b) Concentrators/homefill renewal (after three months and 12 months from the initial starting date, and yearly afterward)

After three months and 12 months from the initial starting date of home oxygen, and yearly thereafter, providers are to give the appropriate Health Canada Regional Office the following medical indications:

an ABG for a resting PaO2 on room air equal or less than 55 mm Hg;
an ABG for a resting PaO2 on room air between 56 and 59 mm Hg, when there is evidence of cor pulmonale, pulmonary hypertension and/or secondary polycythemia;
a walking oximetry for persistent PaO2 between 56 and 59 mm Hg, when there is evidence of desaturation on exertion;
a nocturnal oximetry for persistent PaO2 between 56 and 59 mm Hg, when there is evidence of nocturnal oxygen desaturation;
a resting oximetry for New York Heart Association Stage IV Heart Disease; and,
a resting oximetry and a clinical assessment from a nurse or a caring physician for palliative care when the Client is bedridden and presents dyspnea that cannot be alleviate with medication and/or comfort analgesia.

c) Portable oxygen cylinders/liquid initial and renewal and oxygen for medical travelling Providers are required to give the Regional Office the same medical information described in a) and b) above.

When applicable, NIHB funds oxygen portability for a maximum of eight hours per day away from the principle residence. NIHB oxygen coverage is authorized for primary residence only, with the exception of additional oxygen requirements due to travel for the purpose of attending a medical appointment. While supplemental oxygen for the purpose of attending medical appointments is assessed on a case-by-case basis, it is expected that the Client will use the oxygen concentrator whenever possible.

B. Exclusions

Items excluded from the oxygen benefit list do not apply to the exception process, are not considered for coverage under the NIHB Program, and cannot be appealed. These items include:

oxygen for therapy treatment and/or therapy equipment , such as (but not limited to):
- pain relief (e.g., migraines, cluster headaches, chronic fatigue syndrome, etc.);
- hyperbaric treatment; and,
- oxygen for angina in the absence of documented chronic hypoxemia;
oxygen benefits for outings while the Client is an in-patient in an acute or long-term hospital setting (i.e., Client continues to be the responsibility of the institution);
oxygen to run nebulizers/compressors; and,
oxygen on an 'as needed' (PRN) basis.

C. Provider Services to Support Oxygen Equipment and Supplies

The NIHB Program also requires that provider services to support oxygen therapy:

complete set up within 24 hours of authorization (with the exception of ferry and remote site transportation limitations);
include with set up equipment delivery, safety and care of equipment, and education for the Client on equipment use;
a respiratory therapist (nurse) visit within 72 hours, after three months and every six months thereafter to ensure optimum oxygen therapy (i.e., review prescription, review use of equipment, educate Client on condition); and,
removal of equipment within 72 hours of being informed that it is no longer required.

Long-term oxygen may be considered by the Program after an applicant's condition has been stabilized and the treatment regimen optimized.

3.4.5 Oxygen Equipment and Supplies Benefit Grid

The Oxygen Equipment and Supplies Benefit Grid is available on the Health Canada website.

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3.5 Pressure Garments and Pressure Orthotics Benefits

3.5.1 Pressure Garments and Pressure Orthotics Benefit Categories

The pressure garments and pressure orthotics benefit list covers the following:

Compression garment and lymphedema compression device:

custom-fitted graduated compression garment;
custom-made graduated compression garment; and,
lymphedema compression device sequential extremity pump for lymphedema.

Hypertrophic scar management:

custom-fitted pressure garment;
custom-made pressure garment;
customized pressure orthosis; and,
custom-made pressure orthosis.

3.5.2 Prescriber/Provider Requirements

A compression garment of 20mmHg to 30mmHg and 30mmHg to 40mmHg, as well as a lymphedema compression device, must prescribed by a physician or nurse practitioner. For compression garments over 40mmHg, and all hypertrophic scar pressure garments, the prescriber must be a vascular surgeon, orthopedic surgeon, oncologist, internist, pediatrician, plastic surgeon, physiatrist or general surgeon.

All compression garment and lymphedema compression devices must be provided by a recognized NIHB pharmacist or a recognized NIHB MS&E provider who is a certified compression garment fitter or has an employee who is a certified compression garment fitter. Hypertrophic scar pressure garments must be provided by a recognized NIHB pharmacist or a recognized NIHB MS&E provider who is a certified compression garment fitter and a certified burnscar garment fitter or has an employee who is a certified compression garment fitter and a certified burnscar garment fitter.

3.5.3 Prior Approval Process

Prior approval is required for all pressure garment and pressure orthotic benefits. To initiate the prior approval process, the provider must contact the Health Canada Regional Office.

The NIHB Orthotics-Custom Shoes-Prosthetics-Pressure Garments Prior Approval Form must be completed. In addition to the form, the following documentation is required to support the request:

the prescription;
any other information the provider/physician or nurse practitioner may have to support the request;
a copy of any third-party coverage (e.g., workers' compensation board, private insurance, etc.); and,
the medical guidelines and required information for authorizing pressure garment or pressure orthotic benefits as described in section 3.5.4.

Quick Link

Orthotics-Custom Shoes-Prosthetics-Pressure Garments Prior Approval Form

3.5.4 Pressure Garments and Pressure Orthotics Benefit Policies

A. Medical Guidelines and Required Information

The Health Canada Regional Office adheres to the following medical guidelines when authorizing certain pressure garments and pressure orthotics benefits. They also require specific information from MS&E providers to proceed with such authorizations.

a) Compression stocking/sleeve 20-30, 30-40mmHg and high sustained compression bandages 35mmHg

Providers are required to give the Health Canada Regional Office the Client's diagnosis; the prescription indicating the requested compression; the qualifications and the title of the fitter; whether the item is custom fitted or custom made; as well as the name of the manufacturer and model of the item.

b) Compression stocking/sleeve 40mmHg and up

Providers are required to give the Health Canada Regional Office the Client's diagnosis; the prescription indicating the requested compression; the prescriber's speciality; the qualifications and the title of the fitter; whether the item is custom fitted or custom made; as well as the name of the manufacturer and model of the item.

c) Hypertrophic scar compression garment

Providers are required to give the Health Canada Regional Office the Client's diagnosis and date of onset; the site and extent (i.e., percentage of body affected); the qualifications and the title of the fitter; as well as the name of the garment's manufacturer.

d) Sequential extremity pump and accessories

Providers are required to give the Health Canada Regional Office the Client's diagnosis and cause of lymphedema; the site of the lymphedema; the qualifications of the fitter; as well as the name of the manufacturer and model of the item. Providers should be aware that a sequential extremity pump can be rented on a trial basis for one month before final purchase, but that the rental fee should be applied to the purchase price.

B. Exclusions

Items excluded from the pressure garments and pressure orthotics benefit list do not apply to the exception process, are not considered for coverage under the NIHB Program, and cannot be appealed. These items include:

compression garments for short-term treatment such as pre- and post-surgery, pre- and post-medical treatment, and for post-traumatic oedema because they are temporary conditions following surgical, medical or traumatic situations.

C. Services included in the price

For NIHB Program coverage, the cost of these items must include the following services:

initial assessment to determine type of benefit required;
taking precise measurements of the body part to manufacture the device;
manufacturing the device;
dispensing the benefit, including adjustment and fitting; and,
follow-up visits, as per professional/industry standards.

3.5.5 Pressure Garments and Pressure Orthotics Benefit Grid

The Pressure Garments and Pressure Orthotic Benefit Grid is available on the Health Canada website.

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3.6 Prosthetics Benefits

3.6.1 Prosthetics Benefit Categories

The prosthetics benefit list covers breast, eye (ocular), and lower and upper limb prostheses, as well as prosthetics supplies, and repairs, parts and labour.

3.6.2 Prescriber/Provider Requirements

Breast prosthesis must be prescribed by a physician or nurse practitioner, and provided by a certified mastectomy fitter or by a provider who has a certified mastectomy fitter on staff. Ocular (eye) prosthesis must be prescribed by an ophthalmologist, and provided by a member of the National Examining Board of Ocularists' certified ocularist.

Limb prosthesis must be prescribed by a specialist in the field of physiatry, pediatrics, oncology, orthopaedics or general surgery; and provided by one of the following recognized providers:

certified prosthetists or certified prosthetist orthotist, as certified by the CBCPO for limb prosthesis;
recognized NIHB Pharmacy or recognized MS&E provider for regular stump socks prosthesis; and,
recognized NIHB Pharmacy or recognized MS&E provider who has a certified compression fitter on staff, for stump shrinkers prosthesis.

While it is recognized that access to a medical specialist may be an issue in some areas, a prescription from a specialist is required for the first issue of eye prosthesis and limb prosthesis. A prescription from a general practitioner or nurse practitioner will be accepted for replacement of the eye and limb prosthesis. Providers should be aware that if the replacement is required due to a medical change before the recommended replacement guideline period, a new prescription from a medical specialist may be required.

3.6.3 Prior Approval Process

Prior approval is required for all prosthetic benefits, except for eye prosthesis polishing. To initiate the prior approval process, the provider must contact the Health Canada Regional Office.

The NIHB Orthotics-Custom Shoes-Prosthetics-Pressure Garments Prior Approval Form must be completed. In addition to the form, the following documentation is required to support the request:

the prescription;
the medical diagnosis;
any other information the provider/physician or nurse practitioner may have to support the request;
a copy of any third-party coverage (e.g., workers' compensation board, private insurance, etc.); and,
the medical guidelines and required information for authorizing pressure garment or pressure orthotic benefits as described in section 3.6.4.

Quick Link

Orthotics-Custom Shoes-Prosthetics-Pressure Garments Prior Approval Form

3.6.4 Prosthetics Benefit Policies

A. Medical Guidelines and Required Information

The Health Canada Regional Office adheres to the following medical guidelines when authorizing certain prosthetics benefits. They also require specific information from MS&E providers to proceed with such authorizations.

a) Breast prosthesis

Providers will be required to give the Health Canada Regional Office the date of surgery (initial request only); left, right or bilateral mastectomy; manufacturer and model number of the breast prosthesis and brassiere if questioning the price; and name of the certified mastectomy fitter. Note that breast prosthesis should not be issued before six weeks from the date of surgery.

b) Eye prosthesis/scleral shell

Providers will be required to give the Health Canada Regional Office the diagnosis and/or medical reason for the request and date of the onset.

c) Limb prosthesis definitive

Providers will be required to give the Health Canada Regional Office the date of surgery (initial request only); materials to be used; the detailed assessment (with measurements, when applicable); whether an in-house or external laboratory will be used to manufacture the device; detailed quote/breakdown of components for the prosthesis; and previous NIHB funding for devices and repairs.

d) Limb prosthesis preparatory

Providers will be required to give the Health Canada Regional Office the date of surgery; materials to be used; the detailed assessment (with measurements, when applicable); whether an in-house or external laboratory will be used to manufacture the device; and detailed quote/breakdown of components for the prosthesis.

B. Exclusions

Items excluded from the prosthetics benefit list do not apply to the exception process, are not considered for coverage under the NIHB Program, and cannot be appealed. These include:

Breast prosthesis:
- temporary or swim prosthesis because the NIHB Program does not cover benefits which are used only for sports and/or leisure activities;
- silicone implants used in breast reconstruction because the Program does not provide benefits which need to be surgically inserted into the body, nor does it cover medically unnecessary, 'for cosmetic purposes' items;
- breast prosthesis for failed breast reconstruction, when the Client has not had a mastectomy or lumpectomy;
- Breast prosthesis for cosmetic augmentation of small breasts;
- Breast prosthesis for change in sexual identity; or,
- Silicone nipples.
Limb prosthesis:
- electric and myoelectric prosthesis because this is beyond the scope of the Program;
- a second prosthesis for the same amputation site because NIHB funds only one prosthetic per frequency period for the same site; or,
- early replacement of a prosthetic that has been used beyond manufacturer specifications (e.g., for weight lifting, extreme sports, or basketball).
Testicular implants; or,
Wigs and hairpieces.

C. Services included in the price

For NIHB Program coverage, the cost of these items must include the following services:

initial assessment to determine type of benefit required;
casting of the body part to manufacture the device;
manufacturing the device;
dispensing the benefit, including adjustment and fitting; and,
follow-up visit(s), as per professional association guidelines.

D. Warranty

For breast prosthesis, the warranty must guarantee that the prosthesis will remain satisfactory for fit and against defects for at least two years.
For eye prosthesis, the warranty must guarantee no charge for necessary adjustments for three months after the final fitting except when there has been a change in the Client's medical condition which would prevent a satisfactory fit and a one-year warranty against discoloration and separation of materials.
For limb prosthesis, the warrantee must guarantee against breakage for six months and no charge for necessary adjustments for three months after the final fitting provided that the individual's size or medical condition has not changed significantly.

3.6.5 Prosthetics Benefit Grid

The Prosthetic Benefit Grid is available on the Health Canada website.

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3.7 Respiratory Equipment and Supplies Benefits

3.7.1 Respiratory Equipment and Supplies Benefit Categories

The respiratory equipment and supplies benefit list covers the following:

breathing apparatus and supplies;
respiratory secretion clearance; and,
tracheostomy supplies and equipment.

3.7.2 Prescriber/Provider Requirements

Respiratory equipment and supplies benefits must be prescribed by:

a paediatrician for an apnea monitor;
a medical specialist such as a respirologist or an internal medicine for a bilevel device, oximeter, and volume ventilator;
a physician for continued positive airway pressure; and,
a physician or nurse practitioner for a compressor, flutter valve, high humidity compressor, peak flow meter, pep mask, percussor, or drainage board.

These items must be provided by a recognized NIHB pharmacist, a recognized NIHB MS&E provider or a provider with appropriate health care staff and regulatory affiliations (i.e., registered respiratory therapist/registered nurse familiar with respiratory conditions).

For breathing apparatus benefits (e.g., volume ventilators, bi-level unit, etc.), the provider must have appropriate health care staff and regulatory affiliations (i.e., registered respiratory therapist/registered nurse familiar with respiratory conditions).

3.7.3 Prior Approval Process

Prior approval is required for all respiratory equipment and supplies benefits. To initiate the prior approval process, the provider must contact the appropriate Health Canada Regional Office.

the prescription;
any other information the provider/physician or nurse practitioner may have to support the request;
a copy of any third-party coverage (e.g., workers' compensation board, private insurance, etc.); and,
the medical guidelines and required information for authorizing respiratory equipment benefits as described in section 3.7.4.

Quick Link

Home Oxygen and Respiratory Equipment and Supplies Benefits Approval Form

3.7.4 Respiratory Equipment and Supplies Benefit Policies

A. Medical Guidelines and Required Information

The Health Canada Regional Office adheres to the following medical guidelines when authorizing certain respiratory benefits. They also require specific information from MS&E providers to proceed with such authorizations.

a) Continued positive airway pressure (CPAP)

Providers will be required to give the Health Canada Regional Office the prescription from a physician as well as the following information:
For level one, full baseline and treatment polysomnogragh (PSG) demonstrating diagnosis and response to CPAP or alternative therapy, and the following clinical information:

age, sex, height and weight, BMI, sleepiness scale (ESS or SSS); and,
symptoms of sleep disordered breathing and associated risk factors confirmed by the referring physician.

As PSG testing may not be readily available in some regions, additional clinical information is needed, including:

level two, sleep study (includes apnea/hypopnea index, saturation, heart rate, body position) with baseline and treatment results obtained during two separate nights or nocturnal oxygen saturation and heart rate alone with baseline and treatment results obtained during two separate nights;
clinical information:
- age, sex, height and weight, BMI, sleepiness scale (ESS or SSS);
- symptoms of sleep disordered breathing and associated risk factors;
- evidence that PSG testing was sought including specified waiting period confirmed by the referring physician; and,
other supporting medical documentation (as required).

Prescriptions for interactive CPAP units will not be accepted without appropriate clinical and objective rationale.

Once it has been deemed that the Client qualifies for CPAP, the device can be rented for a three-month period as long as an interface and headgear is purchased for the trial period. After the trial, and upon receiving confirmation from the Client and/or the caring physician or nurse practitioner that the Client is compliant with the usage of the CPAP, the purchase of the CPAP device will be approved with the rental fee of the device deducted from the purchase price.

B. Exclusions

Exclusions are items which will not be provided as benefits under the NIHB Program under any circumstances. For respiratory benefits, exclusions include but are not limited to:

respiratory benefits for outings while the Client is an in-patient in an acute or long-term hospital setting (because the Client continues to be the responsibility of the hospital);
custom-made mask for ventilation, because clients should be provided with stock masks for ventilation;
incentive spirometer, because they are generally used post-operatively to improve a Client's ability to breathe and exercises which have the same impact can be done effectively without an incentive spirometer; and,
therapy treatment and/or therapy equipment, such as (but not limited to) air purifier/cleaner, volumetric exerciser, and environmental protection devices and supplies.

C. Services included in the price

The cost of respiratory benefit items must include connectors with the tubing. When a CPAP, volume ventilator/bi-level unit is purchased, one complete breathing circuit must also be included in the cost.

3.7.5 Respiratory Equipment and Supplies Benefit Grid

The Respiratory Equipment and Supplies Benefit Grid is available on the Health Canada website.

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4.0 Payment and Reimbursement

4.1 Co-ordination of Benefits

When an NIHB-eligible Client is also covered by another public or private health care plan, claims must be submitted to the Client's other health care/benefits plan first.

NIHB will then co-ordinate payment with the other payor on eligible benefit. Claim submissions involving co-payment with a provincial/territorial plan or co-ordination of benefit with a third-party health care plan may be submitted manually or electronically. Manual claims must be accompanied with an Explanation of Benefits Form, available from your provincial/territorial plan or third-party plan, confirming that the Client has exhausted all other coverage.

Claims submitted for NIHB Clients who no longer have coverage with another plan must be supported by a letter from the Client or from the provider on behalf of the Client.

4.2 Dispensing and Claims Submission

Upon entering the MS&E Provider Agreement with the NIHB Program, providers are advised to read and retain an up-to-date Medical Supplies and Equipment (MS&E) Claims Submission Kit. This Kit outlines all of the accountability rules and obligations for providers to ensure that they have the information they need to dispense prescriptions to NIHB Clients and submit claims for payment.

There are a few obligations that bear repeating in this guide. MS&E providers, for example, have one year from the date of service to secure payment, and completion of the days supply field with the appropriate number of days of treatment is mandatory for all claims submitted electronically and on NIHB MS&E claim forms, when appropriate.

4.3 Terms and Conditions of Services

To be eligible for payment of services rendered, MS&E providers must adhere to the terms and conditions of the NIHB Program. These are detailed within section 5.4 of the Medical Supplies and Equipment (MS&E) Claims Submission Kit, including the procedures for verifying Client eligibility and submitting NIHB benefit claims. (www.provider.esicanada.ca)

It is the MS&E provider's responsibility to verify benefit eligibility for the Client, to ensure that no limitations under the Program will be exceeded, and to ensure compliance with NIHB benefits criteria and policies.

Quick Links

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5.0 Appendices

A. Glossary of Key Terms

FNIHB: First Nations and Inuit Health Branch of Health Canada
HICPS: Health Information and Claims Processing Services
MS&E: Medical Supplies and Equipment
NIHB: Non-Insured Health Benefits

B. Client Eligibility

To be eligible for NIHB Program benefits, a person must be a Canadian citizen and have the following status:

is a registered Indian, recognized by INAC, according to the Indian Act; or
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; or
an infant, less than age one (1), whose parent is an eligible client; and
is currently registered or eligible for registration, under a provincial or territorial health insurance plan; and
is not otherwise covered under a separate agreement with federal, provincial or territorial governments.

To facilitate verification, MS&E providers should provide the following Client identification information in each claim:

surname (under which the Client is registered);
given names (under which the Client is registered);
date of birth (dd/mm/yyyy); and,
Client identification number.

It is recommended that MS&E providers ask Clients to present their identification card upon each visit to ensure that Client information is entered correctly and to protect against mistaken identity.

For recognized Inuit Clients, one of the following identifiers is required:

1. Government of the Northwest Territories health plan number, which begins with the letter "T" and is followed by 7 digits. This number is valid in any region of Canada and is cross-referenced to the First Nations and Inuit Health Regional Office client identification number.

2. Government of Nunavut health plan number, which is a 9-digit number starting with a "1" and ending with a "5". This number is valid in any region of Canada and is cross-referenced to the FNIH client identification number.

3. FNIHB Client Identification Number (N-Number), which begins with the letter "N" and is followed by 8 digits. This is a client identification number issued by the First Nations and Inuit Health Branch at Health Canada to recognized Inuit clients.

For eligible First Nations Clients, one of the following identifiers is required:

1. Indian and Northern Affairs Canada registration number, which is a 10-digit number. Also known as the Department of Indian Affairs and Northern Development Treaty or Status number, this registration number is the preferred method of identifying First Nations Clients.

2. Band Number and Family Number, where applicable.

3. FNIHB Client Identification Number (B-Number), which begins with the letter "B" and is followed by 8 digits.

For infants under one year of age who are not yet registered with Indian and Northern Affairs Canada or applicable Inuit associations, MS&E providers must submit the first claim for manual processing. Subsequent claims may be submitted for this infant via point of service with the parent's primary identifier in the client identification number field and the infant's identifiers in the surname, given name, and birth date fields.

More detailed information about Client eligibility is included in section 6.1 of the Medical Supplies and Equipment (MS&E) Claims Submission Kit.

C. Privacy Statement

The NIHB Program respects an individual's right to control who has access to their personal information and the purpose for which that information will be used. When a request for benefits is received, the Program collects, uses, discloses and retains an individual's personal information according to the applicable federal privacy legislation. The information collected is limited to only the information needed for the Program to provide and verify benefits and to ensure that claims paid are in accordance with its terms and conditions.

As a federal government program, NIHB must comply with the Privacy Act, the Canadian Charter of Rights and Freedoms, the Access to Information Act, applicable Treasury Board policies and guidelines, and the Health Canada Security Policy.

D. Appeal Process

Persons eligible for the NIHB Program have the right to appeal the denial of a benefit with the exception of items that are identified as exclusions or insured services. If a Client seeks information about the appeal process, MS&E providers may direct them to the on-line appeal procedures, or to the Provider Claims Processing Call Centre (1-888-511-4666).

Quick Link

Appeal Procedures

E. Audit Program

The NIHB provider audit program ensures that the NIHB Program is accountable for the expenditure of public funds. The Health Information and Claims Processing Services (HICPS) contractor performs this audit function by verifying paid claims against MS&E records to confirm that the claims have been billed in compliance with the terms and conditions of the NIHB Program.

Detailed information about audit procedures and the responsibilities of MS&E providers for these audits are included in section 8.0 of the Medical Supplies and Equipment (MS&E) Claims Submission Kit.

Quick Link

Medical Supplies and Equipment (MS&E) Claims Submission Kit

F. Health Canada Regional Offices - Contact Information

FNIH Atlantic Region

New Brunswick, Newfoundland and Labrador, Nova Scotia, and Prince Edward Island Office
First Nations and Inuit Health
Health Canada

Maritime Centre
1505 Barrington Street
15^th Floor Suite 1525
Halifax, Nova Scotia B3J 3Y6

Telephone: 1-800-565-3294 | (in Halifax) 426-4298
Fax: 1-902-426-8675