Billing and Payment - Drug/Pharmacy
The billing methods available to pharmacy providers depend on the type
of drug items rendered to Non-Insured Health Benefits (NIHB) clients.
Regardless of the billing method used by pharmacy providers, all required
data elements must be supplied to enable the efficient processing and
payment of claims.
 For
further information on any of the available billing methods, format or
record layout, pharmacy providers may contact the Non-Insured Health
Benefits Toll-Free
Inquiry Centre where you can speak with a First Canadian Health Representative.
Drug/Pharmacy providers have these billing options:
All claims for drug items must be submitted through Point Of Service
(POS) technology, except for these two situations, which must be submitted
via paper:
- The first claim for drug items for an infant under one year of age
who has not registered with the Department of Indian and Northern Affairs
Canada (INAC). All subsequent claims for that infant can be processed
on-line once the initial manual claim is submitted to and paid by FCH.
- Re-submissions for drug items after a period exceeding 30 days.
Claims for drug/pharmacy items must have data elements submitted in
the same order as on the Sample
Pharmacy Claim Form. Pharmacy providers submitting claims in formats
other than POS are encouraged to submit claims to First Canadian Health
at least every two weeks.
Note: In certain circumstances and under existing arrangements,
pharmacy providers can submit paper claims for items directly to First
Nations Inuit Health Branch (FNIHB) regions.
Point of Service (POS)
Pharmacy providers must submit claims for drug items and may submit
claims for items via Point of Service (POS), for real-time adjudication.
This option is available to pharmacy providers 24 hours per day, 7 days
a week. All POS claims for amounts over $999.99 must have prior approval.
All NIHB claims submitted through POS must include the information normally
required on the NIHB Pharmacy Claim Form, as well as any additional information
required for POS claims.
There are two types of messaging for claims submitted through the POS
system: CPhA standard messaging and free-format NIHB Health Information
and Claims Processing System (HICPS) system messaging. Providers may
refer to Non-Insured Health Benefits Pharmacy
Claim Form Required Data Elements, for a description and explanation
of NIHB Health Information and Claims Processing System (HICPS) system
terms.
Note: The names of the entry fields displayed on the
pharmacy terminal may be different from the names of the required data
elements due to the specific pharmacy vendor software in place. For clarification
of the field names on the pharmacy terminal, the provider should contact
their software vendor.
Diskette/Tape Submission
Providers have the option to submit claims for eligible Drug/Pharmacy
items dispensed under the NIHB Program on diskette or tape. The format
for submitting claims on diskette/tape is Version 3 of the CPhA Pharmacy
Claim Standard.
For further information, please call the Non-Insured
Health Benefits Toll-Free Inquiry Centre to speak with a First
Canadian Health Representative.
Providers may submit claims for eligible items on plain stock or computer
paper. See Point of Service Data Elements for
a list of required data elements and corresponding field lengths.
The Non-Insured Health Benefits Pharmacy Claim Form was designed for
use in these specific situations only:
- The first drug item claim for an infant under one year of age who
has not yet registered with INAC (Department of Indian and Northern
Affairs Canada);
- Re-submissions for drug items after a period exceeding 30 days;
and
- Drug/pharmacy item claims.
Please direct inquiries related to the completion of this form or requests
for additional supplies to the Non-Insured Health Benefits Toll-Free
Inquiry Centre where you can speak with a First Canadian Health Representative.
See Non-Insured Health Benefits Pharmacy
Claim Form Required Data Elements for a list of the required data
elements for NIHB claims.
For an infant under one year of age not yet registered with INAC, providers
must submit the first claim for payment to FCH for manual processing.
Subsequent claims may be submitted for the infant via Point of Service
(POS), with the parent's primary identifier (such as INAC, client or
band/family number) in the client identification number field and the
infant's identifiers in the surname, given name and birth date fields.
Providers have one year from the date of service to secure payment.
Claims submitted with dates of service more than one year old are rejected
with the R21 message (Period for submitting claims has expired).
The Required Data Elements Table applies only to claims submitted via
POS.
- BIN
- The BIN (Bank Identification Number) may or may not be entered by
the provider (in some cases it is assigned automatically by the software,
eliminating the need to enter it at the pharmacy level). The BIN for
NIHB claims is 610068.
- Version Number
- For example, if a pharmacy's software is based on Version 3 of the
CPhA Pharmacy Claim Standard, the Version Number would be 3. In most
cases, the software assigns this number automatically, eliminating
the need to enter it at the pharmacy level. Providers required to enter
this information manually should contact their software vendor to determine
the version number of their pharmacy software.
- Transaction Code
- Indicates the type of transaction a provider wishes to perform. In
most cases, transaction codes are assigned automatically by the software,
eliminating the need to enter them at the pharmacy level. Providers
required to enter this information manually may use CPhA standard transaction
codes 01-claim, 11-reversal, or 30-daily totals. For information about
the use of transaction codes, providers should contact their pharmacy
software vendor.
- Provider Software ID
- In most cases, the software assigns Provider Software ID numbers
automatically, eliminating the need to enter them at the pharmacy level.
Providers should contact their pharmacy software vendor to automate
the entry of information in this field.
- Provider Software Version
- Indicates version of Provider Software. The Vendor assigns Numbers
automatically.
- Pharmacy ID Code
- This unique, ten-digit identification number is the Pharmacy Number
assigned to the pharmacy by FCH upon registration as an NIHB provider.
- Provider Transaction Date
- Equivalent to Date Of Service, this date should be entered in YYMMDD format
and must be within 30 days of the process date.
- Trace Number
- Trace numbers are unique numbers usually produced sequentially by
the pharmacy's software each time a transaction is transmitted allowing
providers to trace all claims submitted via POS. There may be rare
instances where a provider is required to enter a trace number manually.
For additional information about assigning trace numbers, providers
should contact their software vendor.
- Carrier ID
- Identifies the specific plan type or benefit program, which accepts
responsibility for the claim being submitted (for example, NIHB Program).
In most cases, the software assigns Carrier ID numbers automatically,
eliminating the need to enter them at the pharmacy level. For information
about automating the entry of information in this field, providers
should contact their software vendor.
- Group Number Or Code
- This is a number or code, assigned to identify a specific group of
benefit recipients within a carrier designation, (for example, NIHB
Program clients). In most cases, the software assigns the Group Number
or Code automatically, eliminating the need to enter them at the pharmacy
level. For information about automating the entry of information in
this field, providers should contact their software vendor.
- Client ID # Or Code
- A unique number used to identify a client who is eligible to receive
benefits under the NIHB Program. When submitting claims through POS,
this number may be one of:
- 9 or 10-digit number issued to eligible First Nations clients
by the Department of 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 eligible First
Nations client's band;
- An alpha prefix followed by an 8-digit number issued to certain
eligible First Nations and recognized Inuit clients by First Nations
and Inuit Health Branch (FNIHB); or
- Health care number issued to recognized Inuit clients by the
Government of the Northwest Territories.
- Patient DOB
- The client's date of birth. Partial dates are not acceptable. The
client's date of birth is mandatory for NIHB POS claims, and must be
entered in YYYYMMDD format.
- Patient First Name
- The given name under which the client is registered as an eligible
First Nations or recognized Inuit client. Submission of more than one
given name is preferred to facilitate client verification. Initials
are not acceptable.
- Patient Last Name
- The surname under which the client is registered as an eligible First
Nations or recognized Inuit client.
- Patient Gender
- If entered, must be M-Male, F-Female, or U-Unknown.
- New/Refill Code
- Indicates whether the prescription is new or a refill/repeat. In
most cases, the software assigns this information automatically, eliminating
the need to enter it at the pharmacy level. If the provider's version
of software requires manual entry of this information, these codes
are acceptable:
- N - new prescription
- R - prescription refill/repeat
- Original Rx Number
- This number is assigned to prescriptions on the original date of
service (for example, the number assigned to a "new prescription"),
and is required when submitting claims for refills/repeats. The Original
Prescription Number is usually assigned automatically by the system,
but may have to be entered manually.
- Current Rx Number
- The prescription number assigned by your pharmacy for the item dispensed.
- DIN/GP#/Pin
- The Drug Identification Number (DIN) or item code.
- Quantity
- The quantity (number of units) of the item dispensed. Providers should
enter the actual quantity in this field for each claim.
- Days Supply
- Providers must use this field to enter the estimated number of days
of treatment contained in the prescription.
- Prescriber ID
- 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 Pharmacy/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
- Special Authorization Number Or Code
- An authorization number, issued by FNIHB before the provider dispenses
certain drugs.
- Intervention/Exception Codes
- Intervention/Exception codes are used by providers to override DUR
(Drug Utilization Review) messages, after consulting the prescriber,
the client, or other sources. Standard CPhA intervention codes (listed
in the Drug Utilization Review are accepted by the NIHB HICPS system.
- Drug Cost/Product Value
- The total ingredient or acquisition cost for all units of the drug
or item dispensed.
- Cost Upcharge
- The dollar amount of any mark-up for the item, based on the established
percentage leave blank if not applicable.
- Professional Fee
- The dispensing fee for the item, leave blank if not applicable.
- Previously Paid
- The dollar amount of any portion of the claim that is billable to
a provincial or territorial program or other third party. Leave blank
if not applicable.
- Pharmacist ID
- This field allows providers to identify themselves when overriding
a DUR warning message. Providers should enter their appropriate statutory
number, with the appropriate intervention code.
- Adjudication Date
- This data element is only required for submitting on-line reversals.
In most cases, the software automatically assigns the adjudication
date, eliminating the need to enter it at the pharmacy level. If keyed
manually, the adjudication date must be entered in YYMMDD format.
The date must be within thirty (30) days of original adjudication date.
Paper claims must be submitted if after thirty (30) days beyond original
adjudication date.
Point of Service (POS) Messages and Explanations
Claims submitted via POS to the NIHB HICPS system undergo adjudication
in a matter of seconds. Two types of messages may be displayed to inform
providers of the outcome:
- Standard CPhA codes, used for POS by all Canadian insurance carriers,
are used to communicate the status of a claim. CPhA codes are composed
of two characters (alpha, alphanumeric or numeric), and can be decoded
with pharmacy software packages (for example, C5 -
plan maximum exceeded; C8 - no record of this beneficiary,
etc.). The wording of the CPhA messages displayed on the pharmacy
terminal may be different from the wording used on the statement, due
to the pharmacy software. Providers requiring clarification of CPhA
messages should contact their software vendor. A maximum of 5 CPhA
messages (including DUR messages) can be sent back to the provider
for each claim.
- Free-format messages may also be displayed by the NIHB HICPS system
to clarify the status of a claim in certain situations.
Point of Service (POS) Free-Format
Messages
Free-format messages may appear as part of the NIHB HICPS POS system's
response to a claim submission. POS free-format messages are very similar
to the messages that appear on NIHB Pharmacy/MS&E Claim Statements.
To understand why a specific free format message was sent, please refer
to the description of the corresponding NIHB rejection or warning message,
listed in Pharmacy Claim Statement Messages and
Explanations.
These free-format messages apply only to claims submitted via POS. For
messages that appear on Pharmacy Claim Statements, refer to Point of
Service Free-Format Messages.
- Adjusted to comply with prior approval
- This message is generated in combination with CPhA code 64 (special
authorization number/code error). For more information, refer to the
W17 warning message explanation in the Pharmacy Claim Statement Messages
and Explanations.
- Benefit requires prior approval
- This message is generated in combination with CPhA code CP (eligible
for special authorization), indicating that the benefit claimed requires
prior approval. For more information, refer to the R49 error message
explanation in the Pharmacy Claim Statement Messages and Explanations.
- Claim is reduced to NIHB share
- This message is generated in combination with CPhA code E2 (claim
co-ordinated with government plan). For more information, refer to
the W11 warning message explanation in the Pharmacy Claim Statement
Messages and Explanations and in the Non-Insured Health Benefits List
section.
- Does not comply with prior approval
- This message is generated in combination with CPhA code 64 (special
authorization number/code error). For more information, refer to the
R25 error message explanation in the Pharmacy Claim Statement Messages
and Explanations.
- Infant claim
- This message is generated in combination with CPhA code A6 (submit
manual claim) for the first claim made using supporting parent identification
information. The first claim must be submitted manually using the NIHB
Pharmacy Claim Form. Subsequent claims may be submitted via POS. For
more information, refer to R05 error message explanation in the Pharmacy
Claim Statement Messages and Explanations.
- Alternative coverage. Contact FNIHB
- This message is generated in combination with CPhA code C3 (coverage
expired before service), and may pertain to bands that have now assumed
responsibility of the NIHB Program. The provider should contact their
regional FNIHB office to determine the eligibility of the client. For
more information, refer to the R30 error message explanation in the
Pharmacy Claim Statement Messages and Explanations.
- Prior approval service date violation
- This message is generated in combination with CPhA code 64 (special
authorization number/code error). For more information, refer to the
R26 error message explanation in the Pharmacy Claim Statement Messages
and Explanations.
- Reduced to NIHB pricing guidelines
- This message is generated in combination with CPhA code DJ (drug
cost adjusted). For more information, refer to the W09 warning message
explanation in the Pharmacy Claim Statement Messages and Explanations.
- Submit to provincial/territorial health plan
- This message is generated in combination with CPhA code C6 (patient
has other coverage). For more information, refer to the R20 error message
explanation in the Pharmacy Claim Statement Messages and Explanations.
- The patient is over 65 - submit to ODB
- If claim is submitted from Ontario Region, this message is generated
in combination with CPhA code C6 (patient has other coverage). For
more information, refer to the R08 error message explanation in the
Pharmacy Claim Statement Messages and Explanations.
- Special Authorization for item is used up
- This message is generated in combination with CPhA code 64 (special
authorization number/code error). For more information, refer to R47
error message explanation in the Pharmacy Claim Statement Messages
and Explanations. This message indicates the special authorization
for this item was used up by the previous claim.
- Prior approval for item is used up
- This message is generated in combination with CPhA code 64 (special
authorization number/code error). For more information, refer to R48
error message explanation in the Pharmacy Claim Statement Messages
and Explanations. This message indicates the prior approval for this
item was used up by the previous claim.
- Prior approval number is invalid
- 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 benefit codes were submitted
correctly. If an error was made, supply the correct information following
the claims correction procedures outlined in Point
of Service Reversals.
- Special Authorization required
- This message will appear along with the R06 message and the CPhA
code RP when the data elements of a claim submitted with an SA do not
match the data elements specified in the SA. It will indicate the toll-free
number for the applicable Drug
Exception Centre where providers can call for assistance.
Point of Service (POS) Reversals
The "Claim Reversal" transaction is used to reverse a previously
submitted and paid POS transaction. It is used in situations where the
provider has a need to either correct a previously submitted claim or
totally reverse or cancel a previously submitted claim. There are two
types of provider submitted "Claim Reversal" transactions:
same day reversals and prior day (up to 30 days) reversals.
In order to reverse a claim, the original claim being reversed must
be found on the database. Otherwise, the reversal will be rejected with
an A8 CPhA code.
In both cases, the NIHB HICPS system generates a "Claim Adjustment" reversing
the impact of the original claim. All three claims appear on the provider's
statement: the original claim, the reversal and the corrected claim.
Reversals for Prescribed Medication Not Picked Up by Clients
Compounds
Where the drug item is a compound and re-insertion into the
pharmacy's inventory is not possible, FCH will pay the provider for both
the drug and dispensing fee. Therefore, a reversal is not necessary.
DUR is not affected.
Prescribed Medication
The submission of a claim for a dispensing fee where the client
has not picked up a drug, which can be re-inserted to inventory, only
applies to drugs with a dispensing fee dollar value.
For Non-POS dispensing fee claims, once the original claim containing
both the dispensing fee and the drug item cost has been reversed, an
NIHB Pharmacy Claim Form containing pseudo-DIN 55555555 in the item code
field must be completed. The information on the new claim, with the exception
of pseudo-DIN 55555555, must mirror that of your reversed claim.
For POS dispensing fee claims, once the reversal of the original claim
containing both the dispensing fee and the drug item cost is complete,
the provider must submit a claim online using pseudo-DIN 55555555 in
the item code field. The information on the new claim, with the exception
of pseudo-DIN 55555555, must mirror that of your reversed claim.
Drug Utilization Review (DUR)
Drug Utilization Review Reminder Notice to Pharmacy Providers
When submitted via POS, a claim undergoes a DUR to identify potential
drug-related problems or interactions. The system returns the results
of the analysis to the provider in the form of CPhA standard response
codes along with the adjudication results. The purpose of DUR is not
to replace professional judgement or individualized client care in the
delivery of health care services but, rather, to enhance it with additional
information.
All information obtained through DUR is highly confidential, and disclosed
to health care professionals to prevent potential health risks to the
client. As such, FNIHB requests that providers treat this information
with the utmost sensitivity and confidentiality. DUR is designed to alert
providers to a variety of drug-related problems. These include:
Drug Utilization Review (DUR) Reject and Warning Messages
Drug/Drug Interaction Potential -- Code: ME --
Indicates that drug may interact with another current drug, based on
an accurate days supply submission.
Duplicate Therapy -- Code: MX -- Indicates that the
client has received a drug from the same therapy class.
Duplicate Therapy Multi-Pharmacy -- Code:
MZ -- Indicates that the client has received a drug from
the same therapy class; however, the original prescription was filled
at another pharmacy.
Duplicate Drug -- Code: MW -- Indicates that the client
has received the same drug (same chemical entity) and has used less than
2/3 of the medication based on the days supply.
Duplicate Drug Multi-Pharmacy -- Code: MY --
Indicates that the client has received the same drug (same chemical entity)
and has used less than 2/3 of the medication based on the days supply;
however the original prescription was filled at another pharmacy.
Potential Overuse/Abuse Indicated -- Code: NE -- Indicates potential
overuse/abuse of specified drug entities, the warning code will not prevent
the payment of claims, but will provide pharmacists with additional information
concerning potential problems related to the current drug claim.
DUR information is conveyed in the form of Reject and Warning Messages,
depending on the severity of the potential problem. Claims prompting
the following DUR messages will be rejected: Duplicate drug (MW),
Duplicate drug multi-pharmacy (M) and Drug/drug interaction
potential (ME) (where the free form message indicates "Interact-SV
drug name qty fill date", i.e., a potentially severe interaction).
Following an appropriate intervention, the Provider can re-submit the rejected claim
with a CPhA intervention code (see next page for the applicable intervention
codes).
The warning code and message "NE" is sent to providers for claims that
meet the criteria below:
- Use of Methadone for treatment of opioid dependency (pseudo-DIN
00908835) and, at the same time, use of one or more narcotic drug entities;
- Use of three (3) or more different narcotic drug entities;
- Use of three (3) or more different benzodiazepine drug
entities; and
- Use of three (3) or more narcotic drug entities and three
(3) or more benzodiazepine drug entities.
Additional Drug Utilization Review (DUR) Reject Messages for Saskatchewan
Pilot Projects Only
Drug Not Eligible For Prescription -- Code: NQ --
Indicates that the drug is not eligible for trial Rx.
Not Suitable - Similar Item On Recent Trial Prescription -- Code:
NT -- Indicates that the drug is not suitable - similar item
on recent trial Rx.
Quantity Exceeds Trial Days Period -- Code:
NX -- Indicates that the drug quantity exceeds the trial
day's period.
Insufficient Qty For Trial Days Period -- Code:
NY -- Indicates an insufficient drug quantity for trial day's
period.
Trial Balance Given Too Late -- Code: NZ --
Indicates that the trial balance was given too late.
Trial Balance Given Too Soon -- Code: OA --
Indicates that the trial balance was given too soon.
No Trial Rx On Record, Balance Rejected -- Code:
OD -- Indicates that no trial Rx on record, the
balance is rejected.
Trial Balance Already Dispensed -- Code: OE --
Indicates that the trial balance was already dispensed.
Claims prompting the above DUR messages will be rejected under the Saskatchewan
pilot projects. Following an appropriate intervention, the provider can
re-submit the rejected claims with the CPhA intervention code "MT" or "ND".
Canadian Pharmacy Assocataion (CPHA) Pharmacy Claim Standard Version
3 Intervention Codes and Values
- UA -- Consulted Prescriber and Filled Rx as Written
- UB -- Consulted Prescriber and Changed Dose
- UC -- Consulted Prescriber and Changed Instruction
for Use
- UD -- Consulted Prescriber and Changed Drug
- UE -- Consulted Prescriber and Changed Quantity
- UF -- Patient Gave Adequate Explanation. Rx Filled
as Written
- UG -- Cautioned Patient. Rx Filled as Written
UI -- Consulted Other Sources. Rx Filled as Written
- UJ -- Consulted Other Sources. Altered Rx and Filled
- UL -- Rx not filled - Pharmacist decision (For
Saskatchewan and Manitoba only.)
- UN -- Assessed Patient, Therapy is Appropriate
- MR -- Patient Lost Medication. Rx Refilled
- MT -- Trial Prescription Program
- ND -- Trial Prescription Balance
For additional information about submitting claims through the HICPS
system or on DUR responses, please contact the Non-Insured
Health Benefits Toll-Free Inquiry Centre where you can speak with
a First Canadian Health Representative.
Non-Insured Health Benefits (NIHB) Pharmacy
Claim Form Required Data Elements
The various tables indicate the required data elements for all NIHB
pharmacy claims submitted on paper. Providers must use the Sample
Pharmacy Claim Form when submitting the first claim for infants who
are less than one year old and who do not have an INAC assigned client
number yet. Additionally, providers must use the form on claims submissions
for a drug item(s) where the date of service exceeds 30 days. For information
about submitting claims using the NIHB POS system, magnetic tape or diskettes,
please refer to Billing Methods. The items
in the first column correspond to each field on the claim form. The information
in the third column describes each data element.
The system allows a field length of 30 characters 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. Full submission
facilitates verification of the claimant as an NIHB client and expedites
the processing of NIHB claims.
In this section, you will find data element field name, length and descriptions
for:
Client Information -- Data Elements -- Field
Name (Length) Description
Client Surname (30) The surname under which the client
is registered as an eligible First Nations or recognized Inuit client.
Client Given Name (30) The given name under which the
client is registered as an eligible First Nations or recognized Inuit
client. Submission of more than one given name is preferred to facilitate
client verification. Initials are not acceptable.
Client Date Of Birth (dd/mm/yyyy) (8) The client's
full birth date in day-month--year format (for example, 13/05/1992 represents
13 May 1992). Partial birth dates are not acceptable.
Client Identification No. (10) A unique number used
to identify a client who is eligible to receive benefits under the NIHB
Program. This number may be one of:
- 9 or 10-digit number issued to eligible First Nations clients by
the Department of 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 eligible First Nations client's band,
- An alpha prefix followed by an 8-digit number issued to certain
eligible First Nations and recognized Inuit clients by First Nations
and Inuit Health Branch (FNIHB), or
- Health care number issued to recognized Inuit
clients by the Government of the Northwest Territories and the Government
of Nunavut.
Band No. (3) A 3-digit number (for example, 002, 311)
identifying the band to which an eligible First Nations client belongs.
The band number, when submitted in combination with the client's family
number, is an acceptable alternative to the client identification number
for an eligible First Nations client.
Family No. (5) A 4 or 5-digit number (for example,
1041, 04120) identifying the family unit within the band to which an
eligible First Nations client belongs. The family number, when submitted
in concert with the client's band number, is an acceptable alternative
to the client identification number for an eligible First Nations client.
If the family number on the eligible First Nations client's registration
card has fewer than 5 digits, please insert the appropriate number of
zeros in front of the number.
Client Information (For Each Prescribed
Item) -- Data Elements -- Field Name (Length) Description
Date Of Service (dd/mm/yyyy) (10) The date on which
service was provided to the client, in day-month- year format (for example,
13/05/1992 represents 13 May 1992).
DIN/Item Code (8) The Drug Identification Number (DIN)
or item code.
Quantity (5) The quantity (number of units) of the
item dispensed.
Prescription No. (9) The prescription number assigned
by your pharmacy for the item dispensed.
Drug/Item Cost (6) The total ingredient or acquisition
cost for all units of the drug or item dispensed.
Dispensing Fee (6) The dispensing fee for the item
dispensed. Leave blank if not applicable.
Markup (6) The dollar amount of any mark-up for the
item, based on the established percentage. Leave blank if not applicable.
Third-Party Share (6) 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.
Amount Claimed (6) The sum of the drug/item cost, dispensing
fee, and mark-up for the item, less any third-party share.
Days Supply (3) Estimate of number of days of treatment
contained in the prescription.
Total (6) The total dollar amount claimed for all items
(up to 3) listed on the claim form.
Prescriber (10) 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 Pharmacy 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
Prior Approval No. (8) An authorization number, which
must be issued by FNIHB before the provider dispenses certain drugs.
Pharmacy Information -- Data Elements -- Field
Name (Length) Description
Pharmacy Name (N/A) The name of the pharmacy submitting
the claim, may be formatted as determined by the pharmacy.
Pharmacy Address (N/A) The address of the pharmacy
submitting the claim, may be formatted as determined by the pharmacy.
Pharmacy Number (10) The number assigned to the pharmacy
upon registration as an NIHB provider.
Parent Information (Required For Infants
Less Than One Year Of Age) -- Data Elements -- Field Name (Length) Description
An infant under one year of age, who has not yet registered as an eligible
First Nations or recognized Inuit client, may receive benefits if one
of the infant's parents can be verified as an eligible First Nations
or recognized Inuit 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:
the first claim must be submitted manually using the NIHB Pharmacy Claim
Form. Subsequent claims may be submitted via POS, and this information
about the parent must be provided:
Parent's Surname (30) The surname under which the parent
is registered as an eligible First Nations or recognized Inuit client.
Parent's Given Names (30) The given names under which
the parent is registered as an eligible First Nations or recognized Inuit
client. Submission of more than one given name is preferred to facilitate
client verification. Initials are not acceptable.
Parent's Date Of Birth (Dd/mm/yyyy) (8) The parent's
full birth date in day-month--year format (for example, 13/05/1956 represents
13 May 1956). Partial birth dates are not acceptable.
Parent's Client Identification No. (10) The number
under which the parent is identified as an eligible First Nations or
recognized Inuit client. This number may be one of:
- 9 or 10-digit number issued to eligible First Nations clients by
the Department of 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 eligible First Nations client's band,
- An alpha prefix followed by an 8-digit number issued to certain
eligible First Nations and recognized Inuit clients by FNIHB, or
- Health care number issued to recognized Inuit
clients by the Government of the Northwest Territories and the Government
of Nunavut.
Parent's Band No. (3) A 3-digit number (for example,
002, 311) identifying the band to which an eligible First Nations client's
parent belongs. The band number, when submitted in combination with the
family number, is an acceptable alternative to the client identification
number for an eligible First Nations client.
Parent's Family No. (5) A 4 or 5-digit number (for
example, 1041, 04120) identifying the family unit, within the band, to
which an eligible First Nations client's parent belongs. The family number,
when submitted in combination with the band number, is an acceptable
alternative to the client identification number for an eligible First
Nations client. If the family number on the eligible First Nations client's
registration card has fewer than 5 digits, please insert the appropriate
number of zeroes in front of the number.
Claims Payment Options
Payment is issued 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). Please direct inquiries related
to the payment of claims or the EFT option to the Non-Insured
Health Benefits Toll-Free Inquiry Centre.
Note: In order to facilitate the proper mailing of
cheque payments, providers should ensure that FCH has their current address
information at all times.
Pharmacy Claim Statement
The Sample
Pharmacy Claim Statement accompanies the claims payment cheque
and provides information about each drug, medical supply and equipment
claim processed. If payments are made through EFT, the Pharmacy 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 claims
submissions.
The Pharmacy Claim Statement lists all submitted and entered claims
settled during 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 each claim
was not paid. FCH issues Pharmacy Claim Statements twice a month in either
English or French, depending on the provider's language of choice.
Providers can use the Pharmacy Claim Statement to reconcile accounts
and the statement must be referenced when making inquiries. Please indicate
corrections to claims directly below the existing information and forward
the applicable page of the statement 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 should not resubmit the claim.
An administrative fee of $25.00 will now apply 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 statement
has not been cashed and a sufficient amount of time has passed, 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 facilitate the proper mailing of
cheques, providers should ensure that FCH has their current address information
at all times.
Pharmacy Claim Statement Messages and Explanations
The NIHB HICPS system assigns three-character reject and warning codes
along with messages that appear on the Pharmacy 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 is an ordered list of the NIHB codes, messages and explanations
that may appear on the NIHB Pharmacy Claim Statement, cross-referenced
with the applicable CPhA codes.
NIHB Code: R04
Message: This Is Not An Eligible Benefit
Explanation: The claim was not paid because the item
is not covered under the NIHB Program.
CPhA Codes: D1
NIHB 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 (a) has not used his or her registered
surname, given names, or date of birth or (b) 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.
CPhA Codes: C8
NIHB 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 and vitamins. The Policies
section details benefit limitations. This message will be set along
with the RP code for claims with Special Authorization (SA) whose data
elements do not match those specified in the SA.
CPhA Codes: CD, RP
NIHB 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's pharmacy.
CPhA Code: A3
NIHB Code: R08
Message: The Patient Is Over 65 - Submit To Ont. Drug
Benefit
Explanation: In the Ontario region, the claim has not been paid
because the item is eligible under the ODB (Ontario Drug Benefit) program.
Please direct the claim to the ODB. If the item is only partially covered,
the NIHB Program will pay the outstanding balance.
CPhA Code: C6
NIHB Code: R10
Message: Invalid Provider ID
Explanation: Provider is not registered as an NIHB provider
on date of service.
CPhA Code: B1
NIHB 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:
- Surname
- Given Names
- Date of Birth
- 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 Pharmacy Claim Statement.
CPhA Code: 32, 34, 37, 38
NIHB 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 includes cases where the DIN or item code on the claim is invalid.
This information must be provided on each claim:
- Date of Service;
- DIN or Item Code;
- Prescription Number;
- Prescriber ID;
- Quantity;
- Drug/Item cost; and
- Days supply (drug items only).
The provider should check the claim for missing, incomplete, or erroneous
information and provide the required information by following the claims
correction procedures outlined in Point of
Service Reversals. Further benefit information is provided in the Policies
section.
CPhA Codes: 53, 56, 58, 59, 61, 66, & A2
NIHB Code: R15
Message: Days Supply Must Equal Seven For Dosette Packaging
Explanation: The days supply exceeds seven days on this
submitted claim flagged as a dosette claim (the 'P' in the SSC field
functions as the flag).
CPhA Code: 57
NIHB Code: R20
Message: Submit Claim To Provincial/
Explanation: Territorial Health Plan 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.
CPhA Code: C6
NIHB 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.
CPhA Code: A1
NIHB 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.
CPhA Code: C2
NIHB 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.
CPhA Code: C3
NIHB 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.
CPhA Code: 64
NIHB 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.
CPhA Code: 64
NIHB 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 benefit
codes were submitted correctly. If an error was made, supply the correct
information following the claims correction procedures outlined in Point
of Service Reversals.
CPhA Code: 64
NIHB 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 FNIHB
Regional Office for direction on where to submit the claim.
CPhA Code: C6
NIHB 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.
CPhA Code: 64
NIHB 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.
CPhA Code: 64
NIHB Code: R49
Message: Benefit Requires Prior Approval
Explanation: The claim has not been paid because it
requires prior approval from FNIHB. Benefits that require prior approval
are indicated in the Non-Insured
Health Benefits List section. Prior approval procedures are detailed
in Prior
Approval Process for Pharmacy section.
CPhA Code: CP
NIHB Code: R50
Message: Frequency Of The Claim Exceeds Maximum Allowed
Explanation: The claim has not been paid because the
frequency limit for the drug/item has been exceeded. Drug/Pharmacy benefits
with frequency limits are indicated in each of the benefit categories
in the Non-Insured
Health Benefits List section pharmacy benefits with frequency limits
that do not require prior approval must be prior approved if the claim
exceeds the maximum allowed.
CPhA Code: CO
NIHB 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.
CPhA Code: 34
NIHB Code: R77
Message: Rx# previously paid for same DOS client.
Explanation: Payment denied because all the data elements
match the data elements of a previously settled claim already on file.
See R07
CPhA Code: A3
NIHB Code: W04
Message: Lowest-Cost-Equivalent Pricing Has Been Applied
Explanation: The amount claimed has been reduced to
the amount allowed for the lowest-cost equivalent, according to NIHB
pricing guidelines. Please refer to the details of the NIHB pricing agreement
for the appropriate region.
CPhA Code: D8
NIHB Code: W05
Message: Claims Paid On Parent ID Until 1 st 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 Special
Submission Requirements -- Infant Claims
CPhA Code: N/A
NIHB Code: W09
Message: Drug/Item Cost Is Reduced To NIHB Pricing Guidelines
Explanation: The amount claimed for drug/item cost has
been reduced to conform to NIHB pricing guidelines. Please refer to the
details of the NIHB pricing in the appropriate region.
CPhA Code: DJ
NIHB 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.
CPhA Codes: E2, E3
NIHB Code: W12
Message: Part Of Claim Exceeds Frequency Maximum And
Is Disallowed
Explanation: The amount claimed has been reduced to
conform to the frequency limitation allowed.
CPhA Code: QT
NIHB Code: W13
Message: Quantity Of Claim Is Reduced To Maximum Allowed
Explanation: The amount claimed has been reduced to
conform to the maximum days supply allowed.
CPhA Code: CN
NIHB 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 (a) provision of the full client identification number in
cases where only the client's band number and family number were submitted,
or (b) 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.
CPhA Code: N/A
NIHB Code: W17
Message: Claim Adjusted To Comply With Terms Of Prior
Approval
Explanation: The amount claimed is reduced to comply
with the terms of prior approval set out by FNIHB. The provider should
refer to the Prior Approval Form or prior approval confirmation notice.
CPhA Code: 64
NIHB Code: W19
Message: Dispensing Fee Is Disallowed Or Reduced To
NIHB Guidelines
Explanation: Drug dispensing fee disallowed or reduced
to conform to NIHB dispensing fee guidelines. Please refer to details
of the NIHB pricing in your region.
CPhA Code: DH
NIHB Code: W20
Message: Markup Is Disallowed Or Reduced To NIHB Pricing
Guidelines
Explanation: Drug mark-up disallowed or reduced to conform
to NIHB pricing guidelines. Please refer to details of the NIHB pricing
guidelines in your region.
CPhA Code: DS
NIHB Code: W82
Message: Client Has Not Provided Consent
Explanation: Providers will continue to receive this
warning message on paid claims for clients who have not provided consent.
Providers are asked to disregard this warning message.
CPhA Code: N/A
NIHB 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.
CPhA Code: KB
NIHB Code: N/A
Message: No Reversal Made, Original Claim Is Missing
Explanation: The system is unable to locate the original
claim in order to reverse it. Contact FCH.
CPhA Code: A8
NIHB Code: N/A
Message: Infant Claim
Explanation: The system rejected this claim because
it is the first claim for the child using that INAC number. Please submit
this claim manually.
CPhA Code: A6
NIHB Code: N/A
Message: Special Services Fee Error
Explanation: The system is unable to read the information
in the SSC field.
CPhA Code: 72
NIHB Code: N/A
Message: Previously Paid Error
Explanation: The system is unable to read the information
found in the Interv Cd field.
CPhA Code: 75
NIHB Code: N/A
Message: Call Adjudicator
Explanation: An unknown error occurred. Contact FCH.
CPhA Code: D9
NIHB Code: N/A
Message: Drug Not Eligible For Trial Rx
Explanation: This item not flagged as a trial prescription
drug.
CPhA Code: NQ
NIHB Code: N/A
Message: Not Suitable-Similar Item On Trial Rx
Explanation: The system verified that the client received
this drug before; therefore, it is not eligible for the trial prescription
program.
CPhA Code: NT
NIHB Code: N/A
Message: Quantity Exceeds Trial Days Period
Explanation: The days supply is greater than seven days;
therefore, the drug is not eligible for the trial prescription program.
CPhA Code: NX
NIHB Code: N/A
Message: Insufficient Quantity For Trial Days Period
Explanation: The days supply for the original claim
is less than seven days; therefore, the drug is not eligible for the
trial prescription program.
CPhA Code: NY
NIHB Code: N/A
Message: Trial Balance Given Too Late
Explanation: The provider must submit the second claim
no later than 14 days after the original claim.
CPhA Code: NZ
NIHB Code: N/A
Message: Trial Balance Given Too Soon
Explanation: Providers cannot submit the second claim
until at least four days after the original claim.
CPhA Code: OA
NIHB Code: N/A
Message: No Trial Rx On Record, Balance Rejected
Explanation: Original claim not found on system. Balance
rejected.
CPhA Code: OD
NIHB Code: N/A
Message: Trial Balance Already Dispensed
Explanation: Balance of trial prescription previously
dispensed.
CPhA Code: OE
NIHB Code: N/A
Message: Drug Not Suitable For Dosette Packaging
Explanation: The item has not been flagged as a dosette
claim.
CPhA Code: NR
NIHB Code: N/A
Message: Potential Overuse/Abuse Indicated
Explanation: The client is using
a combination of drug entities that has the potential for misuse or abuse.
See Drug Utilization Review section.
CPhA Code: NE
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