Health Provider Information
This section sets out the policies and procedures for health providers
on the coverage of non-insured health benefits. It contains information
describing the claim submission/payment procedures and the Terms
and Conditions for dental, pharmacy, medical supplies and equipment
services. It also describes the process involved in health provider
audits.
Administration of the Non-Insured Health Benefits
Program
Privacy
Provider Registration
Terms and Conditions
Administration of the Non-Insured Health
Benefits Program
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.
First Canadian Health (FCH), pursuant to a contract with Public
Works and Government Services, administers the Health Information
and Claims Processing System (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, FCH 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. 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.
For further information call the Non-Insured
Health Benefits Toll-Free Inquiry Centre to speak with a
First Canadian Health Representative.
Privacy
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:
- To set out the commitments of the NIHB Program to ensure confidentiality
through responsible and secure handling of personal information
collected for program delivery, administration and management;
and
- To foster transparency, accountability, and increased awareness
of the NIHB Program's privacy procedures and practices.
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.
Provider Registration
Providers wishing to provide services to NIHB clients must register
with FCH. The provider start date in the NIHB Program is established
on the date of registration with FCH as an NIHB provider. The provider
end date in the NIHB Program is established on the date the provider
notifies FCH in writing that the provider no longer chooses to
be an NIHB provider or on the date stated in the letter issued
by FCH informing the provider of the effective date of delisting.
Claims with a service date prior to the start date or subsequent
to end date are not eligible for payment.
Date Format
The date format in use throughout the NIHB Health Information
and Claims Processing System (HICPS), including the outputs from
that system such as the Claims Statement, will reflect this date
format:
DD/MM/CCYY
DD = day in numerical format
MM = month in numerical format
CCYY = year in numerical format (must be '18', '19'or '20')
Example:
July 21, 2001 = 21/07/2001
May 4, 1999 = 04/05/1999
Providers Start and End Dates
The start date is the effective date the provider became a registered
NIHB provider with FCH. The end date is the date that the provider's
registration record is closed or the provider's billing privileges
is terminated either by FCH or by the provider. Termination must
be confirmed in writing.
Claims with a service date prior to the closing of the record
or the termination of billing privileges will be considered for
payment up to one year from the date of service only. Claims with
a service date subsequent to the end date will not be eligible
for reimbursement to the provider.
Non-Insured Health Benefits/First Canadian Health Provider Number
Dental providers will be assigned an individual provider number
upon registration. However, Pharmacy and MS&E providers will
only be assigned an individual provider number upon signing the
First Canadian Health Management Corporation Inc. Pharmacy/MS&E
Provider Agreement. The individual provider number must be used
when submitting all claims for payment and in all communication
with FCH.
Changing Provider Information
All providers may contact the Non-Insured
Health Benefits Toll-Free Inquiry Centre to obtain a copy
of the Provider Information Form for any of these situations:
- Registration and termination;
- Request to submit claims using the Electronic Data Interchange
(EDI) or Point of Service (POS) system;
- Registration of an additional office for dental providers;
- Change of current information (e.g. address); and
- Start, change or stop electronic funds transfer.
The form is faxed for completion by providers. However, providers
may choose to have the NIHB Toll-Free Inquiry Centre Representative
complete the form over the phone on their behalf.
Pharmacy and MS&E providers wishing to change any of the provider
information communicated upon registration may use the Sample
Modifications to Pharmacy/MS&E Information form.
Terms and Conditions
These are the terms and conditions which apply to all services
covered under the Non-Insured Health Benefits (NIHB) Program to
which a health provider must adhere in order to be eligible for
payment for services rendered:
- Client eligibility requirements;
- Provider licensure and eligibility requirements;
- Benefits covered and/or applicable limitations;
- Coordination with other health plans;
- Documentation submission process and requirements;
- Maintenance of relevant documentation and records; and
- Administrative Provider Audit Program.
Note: For Dental Only - use of treatment codes and standard definitions
based on the Canadian Dental Association's Uniform System of Coding
and list of services.
Program policy and claim submission/payment information will be
made available to providers through:
- Regular updates on this Web site;
- Non-Insured Health Benefit Bulletins;
- Non-Insured Health Benefit Newsletters; and
- Ad Hoc broadcast messages.
It is important that providers retain the most current documentation
to ensure program requirements are met.
 Visit
the Resources
and Forms for access to NIHB contact information, bulletins,
newsletters, notices and much more.
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