Policies and Procedures - Medical Supplies and Equipment
Medical Supplies and Equipment (MS&E) benefits are available to
eligible clients when ALL of the criteria are met:
- The item is on the Non-Insured Health Benefits (NIHB)
MS&E List;
- The item is intended for use in a home setting or
other ambulatory care settings;
- Prior approval when required is granted by the First
Nations Inuit Health Branch (FNIHB) Regional Office;
- The item is not available to the client through any
other federal, provincial, territorial or third party health care program;
- The item is prescribed by a physician or medical
specialist as indicated in each of the benefit areas; and
- The item is provided by a recognized provider as
indicated in each of the benefit categories.
For the complete list of eligible MS&E items indicating whether
or not a prior approval is required, please see the medical
supplies and equipment benefit lists.
Prior Approval Requirements
When an MS&E item requires a prior approval, the provider must contact
a First
Nations Inuit Health Branch Regional Office
to initiate the prior approval process. A prior approval form must be
completed in all cases and include specific medical information. Samples
of the forms can be found in the Resources
and Forms section.
In addition to the form, this documentation is required to support the
request:
- The prescription; and
- Other supporting medical documentation (as required).
The form, the prescription and any supporting medical documentation
must be returned to the FNIHB Regional Office for review. If prior approval
is granted, a PA number will be provided for billing purposes. Only then
should the provider proceed with the fabrication/fitting/dispensing of
the item. If a prior approval is not granted the provider will be advised
of the reason.
Exceptions
Items that are not on the NIHB MS&E Benefit List, and that are not
exclusions under the NIHB Program, may be considered on a case by case
basis when an exceptional need is demonstrated.
Exclusions
Exclusions are items that are not listed as benefits under the NIHB
Program and are not available through the exception process. These items
are therefore not considered for coverage under the NIHB Program and
are not subject to the NIHB appeal process. Types of items that are exclusions
under the NIHB Program are listed in each of the Medical Supplies and
Equipment benefit categories.
Appeal Process
When a client is denied a benefit, three levels of appeal are available
under the NIHB Program, which only the client can initiate. At each level,
the appeal must be submitted in witing and must be accompanied by supporting
information from the health care provider. This information should be
included:
- The condition (diagnosis and prognosis) for which
the benefit or service is being requested;
- Alternatives that have been tried;
- Relevant diagnostic test results; and
- Justification for the proposed benefit or service.
The appeal will be reviewed by a health care consultant, who will provide
a recommendation to FNIHB. The final decision will be made by FNIHB,
based on the consultant's recommendation, the client's specific needs,
the availability of alternatives, and NIHB policy.
Information sheets outlining the three levels of appeal and the addresses
are available from the FNIHB Regional Offices and in the Procedures
for Appeals section.
Items that are excluded under the NIHB Program are not subject to the
appeal process.
Coupons and Promotions
NIHB clients shall not directly or indirectly benefit from special promotions
or incentives, including coupons, discounts, points or rebates in the
form of cash and/or, that may be offered by pharmacy or medical supply
and equipment providers. To the extent permitted by such promotions and
applicable law, the coupons, discounts, or rebates should be applied
to the NIHB claim.
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. Requests exceeding
these guidelines may be considered on a case by case basis if a need
is demonstrated.
Equipment and devices will be replaced only when a substantial change
in the condition of the client results in changed needs or if the equipment
or device has deteriorated 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.
Rental
When an MS&E item is rented, the rental agreement must include maintenance
and repair costs as 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.
Warranty
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; and
- Where there is repeated technical failure, the device
will be replaced by the provider at no cost to the NIHB Program.
Co-ordination of Benefits
When clients are covered by another public or private health care plan,
claims must first be submitted to them for coverage. Co-ordination of
benefits for the NIHB Program will be based on the Canadian Life and
Health Insurance Association (CLHIA) Guidelines.
Termination of Alternate Coverage
When an eligible client, who is no longer covered for benefits by another
private or public health care plan, submits a claim to the NIHB Program,
the claim must be accompanied by a letter from the client, or the provider
on behalf of the client, stating that they are no longer eligible under
their previous plan. The date the coverage ended must be included in
the letter.
Quantity Limitations
MS&E 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 claimed with or without a prior approval.
For a listing of eligible benefits, please see the:
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