Reminder to Non-Insured Health Benefits Pharmacy Providers:
Drug Utilization Review on all Point of Service Claims
Please note that all Non-Insured Health Benefits (NIHB) claims will go through
the Drug Utilization Review (DUR) process when submitted via the Point of Service
(POS) system. This also applies to claims which were first sent to a Provincial
or Territorial plan and were not reimbursed by the plan.
This process will ensure that providers are advised of potential drug-related
problems or interactions. As such, the purpose of DUR is not to replace professional
judgment or individualized client care in the delivery of health care services,
but to enhance it with additional information. Once the provider has reviewed
the DUR reject message and has consulted the prescriber, the client, or other
sources where appropriate, the provider can resubmit the rejected NIHB claim
with a valid Canadian Pharmacists Association (CPhA) intervention code.
As stated in NIHB Pharmacy Newsletters released by First Canadian Health (FCH),
the NIHB Program requires that pharmacy providers document the nature of their
intervention directly on the prescription hard copy or on the electronic patient
profile, and that the documented intervention be retained for audit purposes
as supporting documentation. NIHB claims reviewed as part of the DUR process
are subject to audit and may be recovered if the nature of the provider's intervention
is not documented. Appropriate supporting documentation includes but is not
limited to:
- Date of intervention;
- Pharmacist's summary of the intervention;
- Documented communication with the physician, caregiver, and/or patient;
and
- Reason for early refill (medication lost, destroyed, stolen, physician
changed dosage, or patient going out of town for a period greater
than the days' supply remaining on the current refill).
For more information on this subject, please contact the Non-Insured
Health Benefits Toll-Free Inquiry Centre to speak with an FCH Representative.
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