Non-Insured Health Benefits Newsletter

First Canadian Health

News and Information for Our NIHB Providers

NIHB Toll-Free Inquiry Centre: 1-888-511-4666

For our Pharmacy Providers

Spring 2002

News and Views

Welcome to the spring 2002 edition of our NIHB quarterly newsletter. We are now into our fourth year of operations as the claims processor for the NIHB Program of the First Nations and Inuit Health Branch (FNIHB) of Health Canada.

Again, we would like to thank you for your support as you continue to provide quality health services to First Nations and Inuit clients of the NIHB Program.

As always, your comments and questions are welcome. Please contact the FCH NIHB Toll-Free Inquiry Centre at 1-888-511-4666, or send your correspondence to:

FCH Provider Relations
3080 Yonge Street, Suite 3002
Toronto ON M4N 3N1

Spring 2002 NIHB Drug Benefit List (DBL) Update

Please find attached the spring 2002 updates to the NIHB Drug Benefit List (DBL). The changes announced in the updates are reflected in the April 1, 2002 NIHB DBL.

Providers who requested a hard copy of the NIHB DBL will be receiving it shortly.

For those who wish a hard copy, your request must be submitted using the form found in the winter 2001-2002 NIHB Pharmacy Newsletter no later than June 1, 2002. After that time hard copies will not be provided.

The revised NIHB DBL as well as the updates can be downloaded online at the Internet address:

http://www.hc-sc.gc.ca/fnihb/nihb/pharmacy/drugbenefitlist/index.htm

Should you have any questions, please contact the First Canadian Health (FCH) NIHB Toll-Free Inquiry Centre at 1-888-511-4666.

New Time Limit Calculation for Smoking Cessation Therapy

Nicotine patches, Nicotine gum (Nicorette®) and Bupropion tablets (Zyban®)

The following quantities are the maximum amounts of either product that can be issued over a one-year period:

Nicotine Patches:
Habitrol 84 patches; or
Nicoderm 70 patches; or
Nicotrol 70 patches

Gum (Nicorette®):
945 pieces

Bupropion tablets (Zyban®):
180 tablets

(Quantities are based on a 3-month treatment)

Once the maximum quantity has been reached, the client will be eligible again for coverage for Smoking Cessation Therapy 12 months from the day the initial prescription was filled.

Pharmacy Claim Form - Date Format

Please note that dates to be used on paper claim form submissions must always follow this format: DD/ MM/ CCYY.

Failure to use the format indicated may result in claim rejection since the submitted date will not match the date on the system (e. g. in the case of dates of birth).

Emergency Supply

When a drug requiring prior approval is needed on an emergency basis, and timely access to the NIHB Drug Exception Centre is not possible (e.g. statutory holidays and after hours), a pharmacist may dispense an initial course of treatment (maximum of four days). It is important that the pharmacist contact the NIHB Drug Exception Centre as soon as possible for an approval to be backdated to cover the emergency supplies. Additional dispensing of the drug must follow the usual prior approval process.

Once a decision is made on a prior approval request, it is communicated to the pharmacist by fax. If a prior approval is granted, the pharmacist is provided with a Prior Approval number and the details of the approved benefit (description, maximum value, frequency or time limitation, etc). The Prior Approval number must be included on any subsequent claim submitted for the approved drug benefit.

FCH Provider Number

Providers are reminded to indicate their FCH Provider Number (usually a 10-digit number starting with 5 leading zeros, with the exception of Quebec and some pharmacies in British Columbia) and full pharmacy provider name on all paper claims submitted for processing.

Failure to do so will result in the claim being returned for completion.

MS&E Prior Approval Confirmation Letters

Pharmacies selling medical supplies and/ or medical equipment will shortly notice a change to the prior approval confirmation letter mailing process. Individual confirmation letters issued on the same day will be remitted to you in one envelope, rather than in separate envelopes.

Documentation for Overriding Rejected Claims

Drug Utilization Review (DUR) information (or Drug Use Analysis (DUA) in Quebec) is conveyed in the form of warning and information messages depending on the severity of the potential problem. Currently, claims to the NIHB Program prompting the following DUR (DUA) messages will be rejected:

Duplicate Drug (MW)
Duplicate Drug Multi Pharmacy (MY)
Drug/ Drug Interaction Potential (ME)

Following appropriate review and evaluation by the pharmacist, the rejected claim can be resubmitted along with a valid CPhA intervention code.

In the Fall 2001 Newsletter, the NIHB Program outlined the requirement that providers must complete and retain the appropriate documentation of the nature of the intervention. This is documented either directly on the prescription or on any hard copy or electronic version of the patient profile. The Newsletter article indicated that the information was to be available for consultation, if required, during the claims verification/ auditing process.

As a result of conducting a number of on-site audits, the lack of appropriate documentation of the nature of the intervention has been identified as a significant problem. The NIHB Program reaffirms that for all claims submitted after September 30, 2001 and reviewed as part of the claims verification/auditing process, which are not supported by adequate documentation of the nature of the DUR (DUA) intervention as defined above, are subject to reclaim.

Attached are replacement pages for your NIHB Pharmacy/ MS & E Provider Information Kit (PPIK). Please remove the existing pages and insert the revised ones.

Published quarterly by First Canadian Health Management Corporation Inc. at 3080 Yonge Street, Suite 3002, Toronto ON M4N 3N1