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

Fall 2004

Welcome to the fall 2004 edition of the Non-Insured Health Benefits (NIHB) quarterly newsletter. First Canadian Health (FCH) is now in its sixth year of operations as the claims processor for the NIHB Program of the First Nations and Inuit Health Branch (FNIHB) of Health Canada.

Again, FCH 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  

Fall 2004 NIHB Drug Benefit List Update

Please find attached the Fall 2004 updates, which list all changes to the April 1, 2004, NIHB Drug Benefit List (DBL). These updates include the addition and replacement of Drug Identification Numbers (DIN), limited use benefits, drugs removed from the Canadian market and drugs discontinued by the manufacturer effective October 1, 2004.

These updates are reflected in the most recent electronic version of the NIHB DBL. Please refer to the website at the following URL address:

www.hc-sc.gc.ca/fnihb/nihb/pharmacy

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

Faxed Prescriptions

Faxed prescriptions must contain the fax header information, which includes the date sent and the sender's information. Providers must not cut the prescription details out of the faxed page as the fax header information must be visible for audit review. Please refer to your province's or territory's pharmacy legislation for more details on the information required on faxed prescriptions.

Quantity for Nix Cream Rinse 1%®

In all provinces/territories, except for Quebec, claims for Nix Cream Rinse 1%® must be submitted with the quantity in grams (56 grams per bottle). In Quebec, the quantity claimed for Nix Cream Rinse 1%® must be in millilitres (59 millilitres per bottle). Submitted quantities will not be converted to the correct measurement for the provider's province/territory.

If the submitted quantity for Nix Cream Rinse 1%® is in excess of 56 grams (or multiples thereof) and this has resulted in a drug cost overpayment, the excess amount paid will be recovered through the audit program.

Supporting Documentation for CPHA Intervention Codes

Providers are reminded that supporting documentation is required for each claim submitted with a CPhA intervention code.

The NIHB Program requires that providers document the nature of the intervention directly on the prescription hard copy or the electronic patient profile, and that this supporting documentation be retained for audit purposes. This has been set out previously in the following First Canadian Health/NIHB Newsletters: Fall 2001, Spring 2002 (Documentation for Overriding Rejected Claims ) and Summer 2003 ( Required Documentation for Prescriptions Filled Too Soon ).

To clarify, appropriate supporting documentation includes, but is not limited to:

• Date of intervention
• Summary of the intervention by the pharmacist ^ Documented communication with the physician, caregiver, and/or patient
• 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 of the current refill)

This requirement also applies to prescriptions filled too soon which are not rejected with a DUR code due to an error in recording the number of days supply on the previous claim.

Methadone for Opioid Dependancy, Pseudo-DIN 00908835

Effective October 1, 2003 a new policy was implemented for the submission and reimbursement of methadone used for the treatment of addictions for all provinces and territories, excluding Quebec .

Methadone claims must be submitted by using the pseudo-DIN 00908835. Claims submitted with another pseudo-DIN will be subject to recovery through the audit program.

Providers no longer have to contact the National Drug Exception Centre to obtain a special authorization before submitting claims for methadone.

Claims must be submitted once a week (every seven days) at the end of the week . In Ontario, due to legislation, claims will continue to be submitted daily.

Cost of the Drug : The drug cost submitted must be the actual acquisition cost (AAC). The drug cost submitted must reflect the number of milligrams dispensed as opposed to the volume dispensed. Where applicable, the mark-up (MU) submitted must be in accordance with the NIHB Program Pharmacy Pricing Guidelines defined by region.

Dispensing Fee (DF) : The DF, submitted at the end of the week, must be a weekly fee calculated as follows: Day one: 1.5 times the current DF + an " interaction fee " of $3.50. From day 2 to day 7: only the $3.50 interaction fee is reimbursed.

The interaction fee is reimbursed for each dose that the pharmacist witnesses. For doses that the patient carries home, the interaction fee should not be claimed.

In summary, the total claim submitted weekly (every seven days) is the total of the drug cost + the MU (where applicable) + DF. In Ontario, the total weekly amount will be divided by seven and submitted daily.

Claims found to be billed incorrectly will be subject to recovery through the audit program.

Note: For treatment using methadone for other indications, please refer to the NIHB Drug Bulletin dated January 2002.

Drug/Item Cost

Providers are reminded that the amount entered in the "Drug/Item Cost" field on the NIHB Pharmacy Claim Form and the "Drug Cost/Product Value" field on Point of Service (POS) claims must be the total ingredient/ acquisition cost for all units of the drug or item dispensed. Claims should not be submitted with the individual unit cost of the drug or item dispensed.

For further information on the data elements required on claims submitted through POS and the NIHB Pharmacy Claim Form , please refer to Sections 5.4 and 5.8 of your NIHB Pharmacy/MS&E Provider Information Kit .

Claim Correction Procedures for POS Claims Over 30 Days and Manual Claims

The NIHB Pharmacy/MS&E Claim Statement must be used to make corrections to all manual claims, and to POS claims which require a correction after 30 days from the original adjudication date. This applies to:

• A claim correction for incorrect or missing information on the original claim submission
• A claim reversal for drug/benefit items that have not been picked up by the client
• A claim adjustment for benefit items that have been returned unused by the client

Corrections and reversal requests must be clearly indicated below the applicable claim information on the statement. FCH must receive the corrected statement within 12 months of the service date for re-adjudication of the claim.

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

Prescriber ID

Providers are reminded that the Prescriber ID is mandatory for both hard copy and Point of Service (POS) claims. The Prescriber ID must be either the prescriber's License Number or Provincial/Territorial Billing Number, or the prescriber's name.

Claims submitted with a blank "Prescriber" field on the NIHB Pharmacy Claim Form , or the "Prescriber ID" field on POS, will be rejected with the message R14 (INSUFFICIENT BENEFIT INFORMATION TO ADJUDICATE CLAIM ) .

For further information on the data elements required on claims submitted through POS and the NIHB Pharmacy Claim Form , please refer to Sections 5.4 and 5.8 of your NIHB Pharmacy/MS&E Provider Information Kit .

Repairs to MS&E Items

Under the NIHB Program, repairs to MS&E items do not require a prescription from a medical doctor. This applies to both repair labour and the necessary replacement parts associated with a repair, such as batteries.

The "Prescriber" field on the NIHB Pharmacy Claim Form and the "Prescriber ID" field on Point of Service are mandatory fields, therefore claims submitted for repair labour and replacement parts must be submitted with '999Repair' entered in the appropriate field. Claims for repairs submitted without '999Repair' will be rejected with the message R14 (INSUFFICIENT BENEFIT INFORMATION TO ADJUDICATE CLAIM ) .

Providers can download a current version of the NIHB Pharmacy/Medical Supplies and Equipment Provider Information Kit at the NIHB website:

www.hc-sc.gc.ca/ fnihb-dgspni/fnihb/nihb

Providers without internet access can contact the FCH NIHB Toll-Free Inquiry Centre at 1-888-511-4666 .

NHIB Pharmacy Provider Audit

The Non-Insured Health Benefits (NIHB) Audit Program conducted 71 pharmacy provider audits during 2003. The majority (94%) of the audit findings relate to the five categories outlined below. All audit findings were reviewed by an Audit Process Working Group, which includes representatives from the Canadian Pharmacist Association (CPhA), the Canadian Association of Chain Drug Stores (CACDS), and the NIHB Program. We are sharing these findings with you and clarifying the requirements for billing the NIHB Program.

1. Incorrect Billing or Pricing (54% of findings)

As stated in Section 5.12.2 of the NIHB Pharmacy/ MS&E Provider Information Kit : "The total amount billed for the identical prescription, including cost of drugs, mark-up (if applicable) and professional fee must be consistent with the costs and fees established pursuant to the NIHB Program."

Examples of incorrect billing or pricing include:

• Extemporaneous mixtures: Kaopectate claimed, however it is not a listed benefit.

• Extemporaneous mixtures: claims submitted for methadone used for the treatment of addiction with an improper "pseudoDIN", resulting in overpayment (the difference between the actual acquisition cost and ingredient cost billed).

• Methadone for Opioid Dependency: dispensing fees should be submitted weekly, but a number of providers are billing the NIHB Program daily, with the full seven day dispensing fee. In those situations, the weekly dispensing fee must be divided by seven to reflect the daily dispensing fee.
  (See NIHB Drug Bulletin, September 2003 and the article Methadone For Opioid Dependency, Pseudo-DIN 00908835 in this newsletter for details on the reimbursement policy for methadone used to treat opioid dependency)

2. Unauthorized Prescription or Refill (28% of findings)

This category applies to instances where the dispense is not according to the prescription and there is insufficient documentation to support the dispense.

The NIHB Program requires:

a) That all federal and provincial legislation be applied to each dispense.

b) That the requirements of the NIHB Program be met as outlined in the NIHB Pharmacy/MS&E Provider Information Kit , Pharmacy/MS&E Provider Agreement and other NIHB Program documents issued to pharmacies, such as the First Canadian Health/NIHB Program Newsletters and NIHB Program Drug Bulletins.

 
c) That faxed prescriptions contain the fax transmission details, such as the date and the sender's information, to adequately verify the prescription during an on-site audit. (See the article Faxed Prescriptions in this newsletter).

Example: The pharmacist refills the Rx for Metformin 500 mg once beyond the timeframe of prescribed repeats.

The refill must be documented on the Rx hard copy or electronic patient profile as follows:

• Patient requires medication, MD cannot be reached
• Rx refilled one additional time to ensure continuity of treatment
• Signed, Mary Jones, Pharmacist, May 22/04

Rx: March 22, 2003
Mr. Joe Smith
123 Any street
Any town, Any province
Metformin 500 mg
1 tab t.i.d
90 tabs Rep x12
Dr. Scott Bennett
1 River Road

3. Prescription Not Found on Site (7% of findings)

As per provincial regulations and NIHB Program requirements, providers are expected to retain original or faxed prescriptions for review during an on-site audit. If the original or faxed prescription is not found while the auditors are on-site, providers can submit the prescriptions to FCH within a fixed period of time following the on-site audit. Providers can also submit the prescriptions with their response to the letter of audit findings sent to them by FCH following the on-site audit.

4. Fill Too Soon (3% of findings)

A concurrent Drug Utilization Review (DUR) program is part of the NIHB on-line claims adjudication system. When claims are submitted to the NIHB Program, they undergo DUR to identify potential drug-related problems or interactions. The results of the analysis are returned to the provider, in the form of CPhA standard response codes.

A DUR message will be received by the pharmacist if the patient has used less than two-thirds of the medication, based on the days supply from the previous dispense. Although many providers are now documenting interventions, the documentation of overrides remains a concern to the NIHB Program. As reaffirmed in the Fall 2001 and Spring 2002 First Canadian Health/NIHB

Program Newsletters, the reason for the intervention is to be documented either on the patient's electronic profile or on the hard copy of the prescription.

Examples of unacceptable supporting documentation used in the case of overrides include:

• Pharmacist is going on vacation
• Patient requested blister pack
• Use of override code only
• Documentation of overrides provided after the on-site audit (documentation was not written at the time of the dispense to support the override)

Example 4A: The patient lost the tablets of Metformin 500 mg. The pharmacist refills the Rx on April 8/04.

The refill must be documented on the Rx hard copy or electronic patient profile as follows:

• Patient lost Rx, requires an early refill
• Signed, Mary Jones, pharmacist, April 8/04

Rx: March 23, 2004
Mr. Joe Smith
123 Any street
Any town, Any province
Metformin 500 mg
1 tab t.i.d 90 tabs Rep x3
Dr. Scott Bennett 1 River Road

Example 4B: The physician increases the dose of Novasen 325 mg tabs from 1 o.d to 1 t.i.d. Following consultation with the physician, the pharmacist refills the Rx according to the modified dose.

The modified dose must be documented on the Rx hard copy or electronic patient profile as follows:

• Called MD on April 8/04; MD increased dose from 1  
  o.d to 1 t.i.d
• Signed, John White, pharmacist, April 8/04
  

Rx: March 23, 2004
Mr. Joe Smith
123 Any street Any town, Any province
Novasen 325 mg
tabs 50 tabs
1 o.d
Dr. Scott Bennett
1 River Road

5. Discrepancies between quantities prescribed and packaging size (2% of findings)

Audit findings will identify situations where the quantity prescribed does not match the packaging format available on the market, therefore the pharmacist will have to intervene and ensure that the changes are documented properly.

Example 5A: Although the prescribed quantity is 8, the package size is only available in 12's. The quantity prescribed can be modified to 12 following consultation with the physician.

The Rx modification to 12 tabs must be documented on the Rx hard copy or electronic patient profile as follows:

• Called MD on March 25/04; MD approved 12 tabs with 8 repeats
• Signed, Mary Jones, pharmacist, March 25/04

Rx: March 23, 2004
Mr. Joe Smith 123
Any street Any town, Any province
Amerge 2.5 mg tab
8 tabs
X 12 repeats
Ud max. 2 tabs in 24 hours
Dr. Scott Bennett
1 River Road

Example 5B: A quantity is not written on the Rx. The pharmacist dispenses 18 tablets following consultation with the physician.

The quantity must be documented on the Rx hard copy or electronic patient profile as follows:

• Called MD on March 25/04; MD approved 18 tabs
• Signed, Mary Jones, Pharmacist, March 25/04

Rx: March 23, 2004
Mr. Joe Smith 123
Any street Any town, Any province
tabs 1 o.d
Dr. Scott Bennett
1 River Road

Example 5C: The package size is not available in the prescribed 50 g size. The pharmacist dispenses 60 g following consultation with the physician.

The Rx modification to 60 g must be documented on the Rx hard copy or electronic patient profile as follows:

• Called MD on March 25/04; MD approved 60 g
• Signed, Mary Jones, pharmacist, March 25/04

Rx: March 23, 2004
Mr. Joe Smith 123
Any street Any town, Any province
Lamisil cream 50 g
Apply o.d
Dr. Scott Bennett
1 River Road

The NIHB Program's billing requirements are detailed in the NIHB Pharmacy/MS&E Provider Information Kit , First Canadian Health/NIHB Program Newsletters, and NIHB Program Drug Bulletins. These documents are accessible through the Health Canada website at:

www.hc-sc.gc.ca/fnihb-dgspni/fnihb/index.htm

Failure to comply with the requirements of the NIHB Program may result in the recovery of affected paid claims. Providers are advised to review the key documentation in order to be aware of the NIHB Program requirements.

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