1.0 General policies

1.1 Introduction

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 benefits include prescription drugs and select over-the-counter (OTC) medications, dental and vision care, medical supplies and equipment (MS&E), mental health counselling, and medical transportation to access medically required health services that are not available on the reserve or in the community of residence.

Items covered through the MS&E benefit are intended to address NIHB clients' medical needs in relation to basic activities of daily living (ADL) such as eating, bathing, dressing, toileting and transferring. MS&E benefits are covered for use at the client's place of primary residence.

Policies and guidelines are established in accordance with NIHB 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.

The guide and benefit lists contain policies related to NIHB's medical supplies and equipment benefits. Providers will be notified of changes through newsletters and bulletins, available on the Express Scripts Canada NIHB provider and client website. Clients will be notified of changes in the NIHB program update.

If you wish to enrol as an NIHB provider, refer to the provider enrollment webpage, found on the Express Scripts Canada NIHB provider and client website.

Providers and clients who do not have access to the internet can contact the NIHB Call Centre at Express Scripts Canada to request a copy of the documents mentioned above. All questions or comments regarding the MS&E Claims Submission Kit found on the Express Scripts Canada NIHB provider and client website, should also be directed to the NIHB Call Centre at Express Scripts Canada by calling their toll-free number at 1-888-511-4666.

1.2 Information for clients

Providers enrolled with NIHB are paid directly by the program so that clients do not have to pay out of pocket for eligible benefits. Should a client choose to purchase an item or pay for a service, they should confirm all of the following:

• the provider is enrolled with NIHB
• the provider will bill the program directly
• the item or service is eligible for coverage
• the provider will not charge the client any additional fees

For information on client reimbursement, please refer to section 1.17 Client reimbursement.

1.3 Client eligibility

The provider must verify that the individual is eligible for benefits under Indigenous Services Canada's NIHB program and identify any other benefit coverage available to the client, if applicable.

To be eligible, a client must be a resident of Canada, and one of the following:

• a First Nations individual who is registered according to the Indian Act (commonly referred to as a "Status Indian")
• an Inuk recognized by one of the Inuit land claim organizations as outlined in Inuit client eligibility for NIHB
• a child less than 2 years old, whose parent is an NIHB-eligible client

Refer to the Who is eligible for the NIHB program webpage or contact the NIHB regional office for more information.

More detailed information about Client Identification and Eligibility can be found in section 4 of the MS&E Claims Submission Kit, available on the Express Scripts Canada NIHB provider and client website.

1.4 Providers with MS&E specialties

• Providers dispensing specialty MS&E items must indicate the specialty items they wish to dispense on the Provider Billing Agreement form. The required qualifications to dispense such specialty items must be submitted to Express Scripts Canada as part of the enrolment process, upon request. This includes licenses, certificates, and diplomas which support the credentials required for such specialty items
• All information related to specialty items including credentials of the recognized practitioner providing the specialty items/services must be kept in the client file. This may be requested at any time, including the prior approval process

1.5 Terms and conditions of services

1.6 Types of MS&E benefits

1.7 Prescription requirements for MS&E items

Prescriptions and written recommendations from NIHB-recognized prescribers must:

• be written for an individual client
• be written and dated on or before the service date (for example, the date the equipment or supplies are provided/dispensed)
• 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 guide and benefit lists)

Prescriptions and written recommendations must contain all of the following information:

• client's full given names and surnames
• client's date of birth
• date the prescription was issued (day, month and year)
  • prescription is valid for 12 months unless otherwise indicated
  • the date the prescription was faxed or sent is not the prescription date
• quantity and type of item or service being prescribed
• the prescriber/recommender's printed name and license number
• prescriber/recommender's unique hand-written or electronic signature

Note that electronic signatures without a digital certificate or evidence that the signature was applied through a secure authentication process (for example, username and password required) will be deemed invalid. Typing a name (in cursive or print) or copy-pasting a digitized picture of a hand-written signature without any digital certificate or evidence that the signature was applied through an electronic medical recording system are not considered non-reproducible signatures and are therefore not accepted.

Please refer to the appropriate section of the Medical Supplies and Equipment Guide and Benefit Lists for specific benefits that may have additional prescription requirements.

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.

If the NIHB program discerns that a prescription/recommendation does not meet program requirements, the program can request additional information, including a new prescription/recommendation.

Prescriptions not meeting all requirements will be deemed invalid.

1.8 Prescriber/recommender requirements

Prescribers who write prescriptions and recommendations must meet the following criteria:

• be a registered member of a regulatory body
• be an approved NIHB prescriber/recommender
• be operating physically in Canada at the time the prescription/recommendation is written

1.9 Prior approval process

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.

1.10 Special authorization

A special authorization (SA) is a type of authorization that is client specific and allows providers to dispense and claim the approved MS&E items in accordance with the SA approval parameters and pricing policies. Once an item is approved via SA, providers may submit claims directly to Express Scripts Canada without an approval number.

Please note that the prior approval number should not be included when claiming reimbursement from Express Scripts Canada if there is a special authorization assigned, as this will cause adjudication errors.

1.11 Coverage of supplies, maintenance, and repairs of medical equipment covered by another benefit plan or purchased by the client

If medical equipment is funded by another benefit plan or purchased by the client, NIHB may cover associated supplies, maintenance and/or repairs when:

• the supplies, maintenance, or repairs of the medical equipment are not covered by another benefit plan
• the medical equipment is an eligible benefit of the program
• the client qualifies for the medical equipment as per the guide and benefit lists criteria and the following requirements are satisfied:
  • a prescription/recommendation for the medical equipment was obtained from a program-recognized prescriber/recommender
  • the medical equipment was dispensed by a provider that is recognized by the NIHB program to provide the item. This provider does not need to be enrolled in the NIHB program
  • prior approval requirements and necessary information must be submitted (for example, testing/assessment information, diagnosis, device make and model, medical justification, etc.)
• additional information supporting the request is provided (for example, equipment proof of purchase)
• the coverage of supplies, maintenance, and repairs follows the policies set out in the guide and benefit lists

1.12 Recommended replacement guidelines

Recommended replacement guidelines indicate the quantity and frequency at which a benefit is eligible for coverage. Recommended replacement guidelines are based on a client's customary medical needs and the typical device's lifespan. These guidelines are listed within each benefit list.

1.13 Rentals

Rentals are used to support short-term or acute conditions. When an MS&E item is rented, the rental agreement must:

• not exceed 3 months unless otherwise indicated for specific MS&E items outlined in the benefit lists
• include the duration of the rental being requested
• indicate that rental rates are inclusive and include:
  • accessories, supplies (except where indicated in the benefits lists), all equipment maintenance, delivery and pick-up, installation, education, cleaning, adjustments, replacement parts, repair and labour
• provide the monthly rental cost
• stipulate that should the purchase of the item become an option, the amount spent on the rental will be deducted from the purchase price

Please note: reimbursement for rental equipment will not exceed the total purchase price of equivalent equipment.

1.14 Repairs

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 program requirements
• 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 and negligence.

1.15 Warranties

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

1.16 MS&E claims submission and provider payment policies (effective October 1, 2024)

When submitting a request for approval or a claim for payment, providers must follow the MS&E reimbursement model policies and the NIHB Price Policy. Together, these policies are known as the provider payment policies. The policies specify the:

• documentation that must be submitted when requesting for approval
• steps to determine the total dollar amount that can be claimed, known as the eligible claim amount (ECA)

There are documents available to help providers determine their ECA and understand how to submit claims. To be eligible for payment, providers must follow the NIHB program's terms and conditions outlined in their MS&E provider billing agreement, as well as:

• the MS&E Claims Submission Kit, available on the Express Scripts Canada NIHB provider and client website
• the MS&E Guide and Benefit Lists for First Nations and Inuit
• the MS&E price files, available on the Express Scripts Canada NIHB provider and client website

1.17 Client reimbursement

Registered NIHB providers are reimbursed directly by the program, so clients do not have to pay for eligible benefits. Before obtaining an item or service, the client should confirm that the:

• provider is registered with the NIHB program and will bill the program directly
• provider will not charge any additional fees
• item or service is eligible for coverage by NIHB

A client who decides to pay the full cost of an item and request a reimbursement from the program should contact the NIHB Call Centre at Express Scripts Canada or their NIHB regional office before purchase to confirm eligibility of the item and the amount covered by the program.

Please note:

• to be eligible for reimbursement, the medical equipment must be eligible for coverage under the program and the client must meet program criteria for that item, as per the guide and benefit lists criteria
• prescription/recommendation must be obtained from a prescriber/recommender recognized by the program
• the medical equipment must be obtained by a provider that is recognized by the NIHB program to dispense the item. This provider does not need to be enrolled in the NIHB program
• reimbursement will be provided for amounts that fall within pricing as indicated in the MS&E Price Files, available on the Express Scripts Canada NIHB provider and client website
• if a client is eligible for coverage by another benefit plan, only the residual amount not covered by that plan may be submitted for reimbursement consideration
• items purchased from a Canadian online store or third-party sellers using an e-commerce platform with a Canadian domain will be considered if the following conditions are met:
  • the seller has a business that is registered in Canada
  • the business has an address located in Canada
  • the online store has a Canadian web address
  • the item is paid in Canadian dollars
• unless indicated, NIHB only reimburses new items

The following documents must be submitted for reimbursement consideration:

• prescription/recommendation
• prior approval requirements including item-specific information (for example, testing/assessment information, diagnosis, device make and model, medical justification from the prescriber, etc.)
• copy of the original receipts are provided as proof of purchase, except in the case of coordination of benefits (COB), in this case, a copy is acceptable with a benefit statement from the other plan

Find additional information at NIHB Client Reimbursement.

1.18 Coupons and discounts

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 eligible claim amount (ECA) is the residual amount after the application of the promotion.

1.19 Coordination of benefits

Clients who are covered by another public or private health care plan must first submit their claim to the other health care and benefits plan.

The NIHB program will:

• coordinate payment with the other payer on eligible benefits, either manually or electronically
• 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 or program
• continue to apply NIHB criteria for coverage
• coordinate an amount up to the full coverage of the eligible item
• require a copy of the health care plan message indicating refusal to coordinate should the other plan refuse to coordinate with NIHB

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 Call Centre at Express Scripts Canada or the NIHB regional office so that the client's file can be updated.

1.20 Balance billing

Items meeting eligibility criteria will be covered in full according to NIHB MS&E reimbursement policies. Coverage is not provided to upgrade a benefit.

For an item covered by the NIHB program, providers should 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

Certain situations may require a provider to charge a client upfront, such as a coordination of benefits claim or when an item is not covered by the NIHB program. Clients should be informed by the provider that if an item is not covered by the NIHB program, they will be responsible for paying for it without reimbursement from the program.

1.21 Unclaimed MS&E items

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. If an approved item is not picked up after 30 days, it must be returned to the provider inventory. The provider can claim reimbursement only when the equipment or supply is dispensed to the client.

A partial reimbursement may be requested for custom-made or special-order items in situations where one of the following occurs:

• the client does not pick up the item
• the client is unable to use the item due to a worsening or improved condition
• the client passed away after the completion of the order but before 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:

• a claim for reimbursement 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

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).

1.22 Privacy statement

The NIHB program has a responsibility to protect personal information under its control in accordance with the Privacy Act, related Treasury Board privacy policy and directives and is responsible for ensuring the personal information collected is limited to that which is necessary to administer the program.

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.

1.23 Appeal process

NIHB clients can appeal the denial of a benefit except for items that are outside of the program mandate and/or identified as exclusions or insured services. More information is available on the Appealing a decision under the NIHB program webpage.

1.24 Provider Claim Verification Program (PCVP)

As part of the NIHB program's risk management activities, Indigenous Services Canada has mandated its claims processor to maintain a set of pre-payment and post-payment processes, including claim verification activities.

This function incorporates the review of claims against records to confirm compliance with the terms and conditions of the NIHB program. If under any circumstances it is found that a provider has inappropriately billed the program, claim payments will be recovered; either by direct payment from the provider or withheld from future provider claim statements.

Detailed information about the Provider Claims Verification Program and procedures can be found in section 6 of the MS&E Claims Submission Kit, available on the Express Scripts Canada NIHB provider and client website.

1.25 Contact information

For information on billing contact the NIHB Call Centre at Express Scripts Canada.

Provider Phone Number:
1-888-511-4666

Client Phone Number:
1-888-441-4777

For more information on benefits and policies, contact the NIHB program at your applicable NIHB regional office.