Billing and Payment - Medical Supplies and Equipment

First Canadian Health (FCH) administers the Health Information and Claims Processing System (HICPS) on behalf of the Non-Insured Health Benefits (NIHB) Program of the First Nations and Inuit Health Branch (FNIHB) of Health Canada. As such, it is responsible for the processing and payment of all claims for medical supplies and equipment benefits provided under the Non-Insured Health Benefits (NIHB) Program.

Prior Approval Process

If a client is prescribed a Medical Supplies and Equipment (MS&E) item that requires prior approval, the provider must:

• Obtain from the client, the written prescription issued by a physician or medical specialist;
• Obtain client identification information as described in the Client Identification section;
• Contact the First Nations Inuit Health Branch Regional Office to initiate the prior approval process before dispensing the medical supplies and/or equipment 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 FNIHB Regional Office;
• When required, complete the appropriate prior approval form and return it to the FNIHB Regional Office together with all required documents; and
• To avoid delays in the review of the prior approval request, please ensure that all of the fields of the prior approval form are fully completed.

The Medical Supplies and Equipment Information Policies and Procedures section provides details on the required forms and documents.

Confirmation

If a prior approval is granted, the provider will be given a Prior Approval (PA) number for billing purposes. The provider should record this number and make note of the approval details (For example, description, quantity, dollar value, and any frequency or time limitations). Only then should the provider proceed with the fabrication, fitting and dispensing of the item.

A confirmation letter with the applicable dates and prior approval details will be mailed to the provider. This confirmation letter should be retained for billing purposes.

If a prior approval is not granted, the provider will be advised of the reason.

Claim Submission with a Prior Approval

When submitting a claim for an item that has been prior approved, please ensure that the PA number, the date of service or the dates of the service period are included and correspond to the details of the confirmation letter. These dates are important as they will determine the payment of the claim.

On a prior approval for a one time item (with no start and end date), the date of service on the claim must be the same or after the date of the prior approval, or the claim will be rejected.

On a prior approval with a start and end date, the date of service on the claim must be within the start and end date on the prior approval or the claim will be rejected.

On a prior approval for one of the delivery charge codes (99400819, 99400820 and 99400262), providers are required to submit a copy of the way-bill of the delivery charges in order to be reimbursed.

When a prior approval is set up for a one-year period, billing must be in accordance with client usage. No more than a three-month supply can be dispensed and billed at a time.

Billing Methods

Providers can bill FCH using one of these billing methods:

• Diskette/Tape submission;
• Computer printout; and
• NIHB MS&E Claim Form.

Regardless of the billing method used, all required data elements must be supplied to ensure the efficient payment of claims. Data elements must be submitted in the same order as on the Non-Insured Health Benefits Sample Medical Supplies and Equipment Claim Form. Providers are encouraged to submit claims to FCH at least every two weeks.

Providers may contact the Non-Insured Health Benefits Toll-Free Inquiry Centre for further information on any billing method, format or record layout.

Diskette/Tape Submission

Claims may be submitted on diskette or on tape. A list of required data elements and corresponding field lengths are identified below under NIHB Medical Supplies And Equipment Claim Form Required Data Elements.

Computer Printout

Claims may be submitted on plain stock or computer paper. A list of required data elements and corresponding field lengths are identified under NIHB Medical Supplies And Equipment Claim Form Required Data Elements.

NIHB Medical Supplies and Equipment Claim Form

Claims may be submitted on the Non-Insured Health Benefits Sample Medical Supplies and Equipment Claim Form. Inquiries related to its completion or requests for a supply of forms should be directed to the Non-Insured Health Benefits Toll-Free Inquiry Centre.

A list of the required data elements for NIHB claims are identified under NIHB Medical Supplies And Equipment Claim Form Required Data Elements.

Note: The client address section of the NIHB MS&E Claim Form must be completed prior to sending to First Canadian Health for payment. If the client address field is not completed, the form will be returned to the provider for completion.

Special Submission Requirements - Infant Claims

Claims for infants under one year of age, who do not have an acceptable client identification number, should be submitted with supporting parent identification using the Non-Insured Health Benefits Sample Medical Supplies and Equipment Claim Form.

One Year Billing Policy

Providers have one year from the date of service to secure payment. Claims submitted with dates of service more than one year after services have been rendered are rejected with the R21 message (period for submitting claims has expired).

NIHB Medical Supplies and Equipment Claim Form Required Data Elements

Data element descriptions for:

• Client Information;
• Claim Information for Each Prescribed Item; and
• Medical Supplies and Equipment Provider Information

The Data Elements Descriptions contains the required data elements for all NIHB MS&E claims and applies only to claims submitted on paper and computer printout.

For information about submitting claims using magnetic tape or diskettes, please see Billing Methods.

The items in the first column correspond to each field on the claim form. The number in the second column is the field length specification for claims submitted on computer printouts or diskettes. The information in the third column describes each data element.

A field length of 30 characters has been allowed for each of the surname and given name entries to ensure that the full surname and all given names presented by the claimant can be submitted on the claim.

Submission of all required client data elements is necessary to verify the claimant as an NIHB client.

Data Element Descriptions -- Client Information

Field Name: *Client Surname
Length: 30
Description: The surname under which the client is registered.

Field Name: *Client Given Name
Length: 30
Description: The given name(s) under which the client is registered. Submission of more than one given name is preferred to facilitate client verification. Initials are not acceptable.

Field Name: *Client Date Of Birth (DD/MM/YYYY)
Length: 8
Description: The full birth date in dd/mm/yyyy format (For example, 13/05/1992 represents 13 May 1992). Partial birth dates are not acceptable.

Field Name: *Address /Apt/City/
Length: Prov./Postal Code
Description: N/A
The current and exact address of the client.

Field Name: *Client Identification No.
Length: 10
Description: A unique number used to identify a client who is eligible to receive benefits under the NIHB Program. This number may be one of:

• a 9 or 10-digit number issued to eligible First Nations clients by Indian and Northern Affairs Canada (INAC),
• an alpha prefix followed by an 8-digit number issued to certain eligible First Nations and recognized Inuit clients by FNIHB, or
•  an alpha prefix followed by a 7-digit health care number issued to recognized Inuit by the Government of the Northwest Territories or the Government of Nunavut.

Field Name: *Band No. (Not Applicable To Inuit Clients)
Length: 3
Description: A 3-digit number (For example, 002, 311) identifying the band to which the client belongs. The band number, if submitted in combination with the client's family number, is an acceptable alternative to the client identification number for an eligible First Nations client.

Field Name: *Family No. (Not Applicable To Inuit Clients)
Length: 5
Description: A 4 or 5-digit number (For example, 1041, 04120) identifying the family unit, within the band, to which a client belongs. The family number, if submitted in combination with the client's band number, is an acceptable alternative to the client identification number. If the family number has fewer than 5 digits, please insert the appropriate number of zeros in front of the number (For example, 125 becomes 00125).

Data Element Descriptions -- Claim Information for Each Prescribed Item

Field Name: Date Of Service (DD/MM/YYYY))
Length: 10
Description: The date on which service was provided to the client, in dd/mm/yyyy format (for example, 13/05/1992 represents 13 May 1992).

Field Name: *Din/Item Code
Length: 8
Description: The item code.

Field Name: *Quantity
Length: 5
Description: The quantity (number of units) of the item dispensed.

Field Name: *Prescription No.
Length: 9
Description: The prescription number assigned by the MS&E provider for the item dispensed.

Field Name: *Item Cost
Length: 6
Description: The total acquisition cost for all units of the item dispensed.

 Field Name: Dispensing Fee
Length: 6
Description: The dispensing fee for the item. Leave blank if not applicable.

Field Name: Markup
Length: 6
Description: The dollar amount of any mark-up for the item, based on the established percentage. Leave blank if not applicable.

Field Name: *Third-Party Share
Length: 6
Description: The dollar amount of any portion of the claim which is billable to a provincial or territorial program or other third party. Leave blank if not applicable.

Field Name: *Amount Claimed
Length: 6
Description: The sum of the item cost, dispensing fee, and mark-up for the item, less any third-party share.

Field Name: Days Supply
Length: 3
Description: Estimate of the number of days of treatment contained in the prescription.

Field Name: Total
Length: 6
Description: The total dollar amount claimed for all items (up to 3) listed on the claim form.

Field Name: *Prescriber
Length: 10
Description: The prescriber number as entered by the provider on the claim submission must be the same as required by the provincial/territorial pharmacare program. Claims for repair labour and replacement parts must be submitted with '999Repair' in the prescriber field, or they will be rejected on the NIHB MS&E Claim Statement with an R14 error (Insufficient Benefit Information to Adjudicate Claim).

• British Columbia       Physician License Number
• Alberta       Physician License Number
• Saskatchewan       Physician's Provincial Billing Number
• Manitoba       Physician License Number
• Ontario       Physician License Number
• Quebec       Physician License Number
• New Brunswick       Physician's Provincial Billing Number
• Nova Scotia       Physician License Number
• Prince Edward Island       Physician License Number
• Newfoundland       Physician License Number
• Yukon       Physician's Territorial Billing Number
• Northwest Territories       Physician License Number
• Nunavut       Physician License Number

Data Element Descriptions -- Medical Supplies and Equipment Provider Information

Field Name: *Prior Approval No.
Length: 8
Description: An authorization number, which must be issued by FNIHB before the provider dispenses certain drugs, medical supplies and most medical equipment.

Field Name: *Provider/Supplier Name
Length: N/A
Description: The name of the provider/supplier submitting the claim. May be formatted as determined by the provider/supplier.

Field Name: *Provider/Supplier Address
Length: N/A
Description: The address of the provider/supplier submitting the claim. May be formatted as determined by the provider/supplier.

Field Name: *Provider/Supplier Number
Length: 10
Description: The number assigned to the provider/supplier upon registration as an NIHB provider with FCH.

Parent Information (required for infants under one year of age)

An infant under one year of age who does not yet have a client identification number may receive benefits if one of the infant's parents can be verified as an eligible client. In such a case, the infant's surname, all given names, and the date of birth must be entered in the appropriate fields in the Client Information section of the claim (Note: these claims may only be submitted using the Non-Insured Health Benefits Sample Medical Supplies and Equipment Claim Form), and this information about the parent must be provided:

Field Name: *Parent's Surname
Length: 30
Description: The surname under which the parent is registered.

Field Name: *Parent's Given Names
Length: 30
Description: The given names under which the parent is registered. Submission of more than one given name is preferred to facilitate client verification. Initials are not acceptable.

Field Name: *Parent's Date Of Birth (DD/MM/YYYY)
Length: 8
Description: The parent's full birth date in day-month-century-year format (for example, 13/05/1956 represents 13 May 1956). Partial birth dates are not acceptable.

Field Name: * Address /Apt/ City / Prov./Postal Code
Length: N/A
Description: The current and exact address of the parent.

Field Name: *Parent's Client Identification No.
Length: 10
Description: The unique number under which the parent is registered. This number may be one of:

• 9 or 10-digit number issued by Indian and Northern Affairs Canada (INAC),
• 3-digit band number, immediately followed by the 4 or 5-digit family number identifying the family unit within the client's band,
• An alpha prefix followed by 8 digit number issued to certain eligible clients by FNIHB, or
•  A health care number issued by the Government of the Northwest Territories or Nunavut.

Field Name: *Parent's Band No. (Not Applicable To Inuit Clients)
Length: 3
Description: A 3-digit number (For example, 002, 311) identifying the band to which the infant's parent belongs. The band number, if submitted in combination with the family number, is an acceptable alternative to the INAC client identification number.

Field Name: Parent's Family No. (Not Applicable To Inuit Clients)
Length: 5
Description: A 4 or 5-digit number (For example, 1041, 04120) identifying the family unit, within the band, to which the infant's parent belongs. The family number, if submitted in combination with the band number, is an acceptable alternative to the INAC client identification number. If the family number has fewer than 5 digits, please insert the appropriate number of zeros in front of the number.

Claim Payment Options

Claims are paid on behalf of Health Canada twice a month (mid and end of month). Payment is made by cheque or through direct-deposit, also known as electronic funds transfer (EFT). To apply for the EFT payment option, complete the Sample Modifications to Pharmacy/Medical Supplies and Equipment Information Form. Inquiries related to the payment of claims or the EFT option should be directed to the Non-Insured Health Benefits Toll-Free Inquiry Centre.

Note: In order to ensure cheque payments are mailed properly, providers should ensure that FCH has current address information at all times.

Non-Insured Health Benefits Medical Supplies and Equipment Claim Statement

The Non-Insured Health Benefits Sample Medical Supplies and Equipment Claim Statement accompanies the claims payment cheque and provides information about each medical supply and equipment claim processed. If payments are made through EFT, the NIHB MS&E Claim Statement is mailed to the provider's business address. The statement may provide additional client identification information which should be added to the client's records and be used for all future submissions.

The NIHB MS&E Claim Statement lists all submitted and entered claims which were settled in the current period, adjusted claims during the current period, and claims rejected during the current period. Rejected claims include the appropriate reject message explaining the reason why each claim was not paid. NIHB MS&E Claim Statements are issued twice a month in either French or English, depending on the provider's language of choice.

The NIHB MS&E Claim Statement may be used to reconcile the providers' account and should be referenced when making inquiries. Corrections to claims should be indicated directly below the existing information and forwarded to FCH within 12 months of the service date for re-adjudication of the claim. The existing information should not be altered or erased. Providers who resubmit using a claim form must clearly indicate the claim is a resubmission.

An administrative fee of $25.00 applies to requests for duplicate statement requests. Requests must be made in writing to FCH and include a cheque for $25.00. If the FCH payment cheque corresponding to the duplicate statement being requested has not been cashed and enough time has passed that the original statement should have been received in the mail, the $25.00 administrative fee will not apply and the provider's $25.00 cheque will be returned with the copy of the statement.

Note: In order to ensure cheque payments are mailed properly, providers should ensure that FCH has the current address information at all times.

NIHB Medical Supplies and Equipment Claim Statement Messages and Explanations

The NIHB HICPS system assigns three-character reject and warning codes along with messages that appear on the NIHB MS&E Claim Statement. A reject code, composed of an 'R' followed by two numeric characters and a text message, explains why the claim was rejected. A warning code, composed of a 'W' followed by two numeric characters and a text message, explains that the claim was adjudicated with modifications.

Here are explanations of all codes and messages, which may appear on the NIHB MS&E Claim Statement:

Code: R04
Message: This is not an eligible benefit
Explanation: The claim has not been paid because the item is not covered under the NIHB Program.

Code: R05
Message: Claimant could not be verified as an NIHB client
Explanation: The claim cannot be paid because the claimant could not be verified as an NIHB client. The verification problem may be due to the fact that the claimant

1. has not used his or her registered surname, given names, or date of birth or
2. has made an error in specifying the client identification number.

In such cases, it may only be necessary for the claimant to provide more accurate client identification information. However, if the claimant is not registered as an NIHB client, it will be necessary for the claimant to do so before service can be provided.

Code: R06
Message: Client is not eligible for this benefit
Explanation: The claim has not been paid because the item is not covered under the NIHB Program due to the age or gender of the claimant. This restriction applies to benefits such as incontinence supplies.

Code: R07
Message: This is a duplicate claim
Explanation: The claim cannot be paid because it is a duplicate of a claim previously submitted by the provider.

Code: R10
Message: Invalid provider ID
Explanation: Provider is not registered as an NIHB provider on date of service.

Code: R12
Message: Insufficient client information to adjudicate claim
Explanation: The claim did not provide sufficient information to determine if the claimant is an NIHB client. To facilitate client verification, this client information must be provided for each claim:

1. Surname;
2. Given Names;
3. Date of Birth; and
4. Client Identification Number.

Please check your claim for missing or incomplete information and provide the required information by following the claims correction procedures outlined in Non-Insured Health Benefits Sample Medical Supplies and Equipment Claim Statement. Further information on client identification requirements is provided in Client Identification section.

Code: R14
Message: Insufficient benefit information to adjudicate claim
Explanation: The claim did not provide sufficient information to determine if the claimed item is eligible under the NIHB Program. This information must be provided on each claim:

1. Date of Service;
2. Quantity;
3. Item Code;
4. Item Cost;
5. Prescription Number; and
6. Prescriber ID.

The provider should check the claim for missing or incomplete information and provide the required information by following the claims correction procedures outlined in Non-Insured Health Benefits Sample Medical Supplies and Equipment Claim Statement.

Code: R20
Message: Submit claim to provincial/ territorial health plan
Explanation: The claim has not been paid because a provincial or territorial health plan covers the item. This includes cases in which a provincial or territorial patient co-pay or user fee system exists and NIHB has already paid the maximum amount for which the client is responsible. Please direct the claim to the appropriate plan.

Code: R21
Message: Period for submitting claims has expired
Explanation: The claim has not been paid because the claim was submitted more than one year after the service was rendered.

Code: R23
Message: Service provided prior to client's start date
Explanation: The claim cannot be paid because the date of service is prior to the start date for the client's NIHB coverage.

Code: R24
Message: Service provided after client's end date
Explanation: The claim cannot be paid because the date of service is after the end date for the client's NIHB coverage.

Code: R25
Message: Claim does not comply with terms of prior approval
Explanation: The claim has not been paid because it does not comply with the terms of the NIHB prior approval. Refer to your copy of the Prior Approval Confirmation.

Code: R26
Message: Prior approval service date violation
Explanation: The claim has not been paid because the date of service is either before the approval date or after the expiry date of the prior approval.

Code: R27
Message: Prior approval number is invalid
Explanation: The claim has not been paid because the prior approval number is invalid for the specified client and benefit. The provider should check their records to determine if the prior approval number, the associated client identification number, and the item codes were submitted correctly. If an error was made, supply the correct information following the claims correction procedures outlined in Non-Insured Health Benefits Sample Medical Supplies and Equipment Claim Statement.

Code: R30
Message: Client has alternative coverage. Contact FNIHB
Explanation: The claim has not been paid because FNIHB records indicate that the client has alternative coverage for the indicated item. In some cases, the client may belong to a band that has assumed responsibility of the NIHB Program. Please contact the applicable FNIHB Regional Office for direction on where to submit the claim. The numbers and addresses of the FNIHB Regional Offices are provided at the beginning of the Kit.

Code: R47
Message: Special authorization for this item used up by previous claim
Explanation: The claim has not been paid because special authorization for this item has been used up by a previous claim.

Code: R48
Message: Prior approval for this item used up by previous claim
Explanation: The claim has not been paid because prior approval for this item has been used up by a previous claim. Refer to your copy of the Prior Approval Confirmation.

Code: R49
Message: Benefit requires prior approval
Explanation: The claim has not been paid because it requires prior approval from the FNIHB Regional Office. Benefits, which require prior approval, are indicated in Non-Insured Health Benefits Medical Supplies and Equipment Benefit Lists. Prior approval procedures are detailed in Prior Approval Process.

Code: R50
Message: Frequency of the claim exceeds maximum allowed
Explanation: The claim has not been paid because the frequency limit for the item has been exceeded. Benefits with frequency limits are indicated in each of the benefit categories found in the Medical Supplies and Equipment Benefit Lists. Benefits with frequency limits that do not require prior approval must be prior approved if the claim exceeds the maximum allowed.

Code: R66
Message: Date of service must be after DOB
Explanation: The claim has not been paid because the client's date of birth is after the date of service.

Code: W05
Message: Claims paid on parent ID until first birthday only
Explanation: The claimant could not be verified as an NIHB client. However, since the claimant is an infant under one year of age, and the infant's parent was verified as an NIHB client, the claim has been paid. This provision allows time for parents to register the infant and only applies until the infant's first birthday. Claims for services provided after the infant's first birthday will be rejected if the infant cannot be verified as an NIHB client. Additional information on client identification requirements for infants is provided in Client Identification.

Code: W09
Message: Drug/item cost is reduced to NIHB pricing guidelines
Explanation : The amount claimed for the item cost has been reduced to conform to NIHB pricing guidelines. Please refer to the details of the NIHB pricing guidelines in your region.

Code: W11
Message: Claim is reduced to NIHB share
Explanation: The item is partially covered by a provincial, territorial, or third party plan. The amount claimed is reduced to the correct NIHB share.

Code: W13
Message: Quantity of claim is reduced to maximum allowed
Explanation: The amount claimed has been reduced to conform to the maximum allowed.

Code: W14
Message: Please note corrected client ID for future claims
Explanation: The claimant was verified as an NIHB client on the basis of the client information provided. However, the submitted client information has been corrected to exactly match the identifiers under which the client is registered as an NIHB client. The corrections may include:

• Provision of the full client identification number in cases where only the client's band number and family number were submitted, or
• Correction of a submitted band number, family number, surname, given names, or date of birth.

Please use the corrected client ID on future claims to facilitate client verification.

Code: W17
Message: Claim adjusted to comply with terms of prior approval
Explanation: The amount claimed is reduced to comply with the terms of the prior approval set out by the FNIHB Regional Office. The provider should refer to the Prior Approval Form or the Prior Approval Confirmation.

Code: W19
Message: Dispensing fee is disallowed or reduced to NIHB guidelines
Explanation: The dispensing fee has been disallowed or reduced to conform to NIHB dispensing fee guidelines. Please refer to the details of the NIHB pricing in your region.

Code: W20
Message: Markup is disallowed or reduced to NIHB pricing guidelines
Explanation: The mark-up has been disallowed or reduced to conform to NIHB pricing guidelines. Please refer to details of the NIHB pricing guidelines in your region.

Code: W82
Message: Client has not provided consent
Explanation: The NIHB Program has not been provided with a Consent Form from this client.

Code: W99
Message: This claim is in suspense
Explanation: This claim requires additional investigation before it can be fully adjudicated. No action is required by the provider at this time. The adjudication result will appear on a future statement.