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 2004

News and Views

Welcome to the spring 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

Spring 2004 NIHBDrug Benefit List Update

Please find attached the Spring 2004 updates, which list all changes to the April 1, 2003, 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 April 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

To be added to the distribution list for a hard copy of the April 1, 2004, reprint of the full NIHB DBL, submit a request using the form below. Please fax the entire page to (613) 941-6249 no later than June 1, 2004. After that time, hard copies of the April 1, 2004, reprint of the NIHB DBL will not be provided.

Name:
Provider Number:
Street Address:
City:
Prov.:
Postal Code:
Email:

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

New Approach to the NIHB Program's Consent Initiative

On February 4, 2004, Health Canada announced a new approach to the NIHB Program's Consent Initiative. The new approach means that the March 1, 2004, deadline for the submission of consent forms by NIHB First Nations and Inuit clients no longer applies. Under this new approach, the NIHB Program will not require a signed consent form for day-to-day processing activities and program administration. NIHB clients will therefore continue to receive benefits for which they are eligible even if they have not signed a consent form.

Health Canada would like to express its appreciation to those providers who assisted in, and supported, the NIHB Program's Consent Initiative.

For more details on the new approach to the initiative, please visit Health Canada's website at the following URL address:

www.hc-sc.gc.ca/fnihb/nihb/consent/urgent_noticefeb.htm

Providers may also contact the NIHB Consent Information Centre at 1-888-751-5011.

Consent Warning Message : W82

Providers will continue to receive the warning message W82 (Client has not provided consent) on paid claims for clients who have not provided consent.

Providers are asked to disregard this warning message as the March 1, 2004, deadline no longer applies.

Questions regarding the W82 warning message can be directed to the FCH NIHB Toll-Free Inquiry Centre at 1-888-511-4666.

Change in Benefit Status - Darvon© and 642© (Propoxyphene)

The NIHB Program is presently faxing letters to prescribers to advise them that effective June 1st, 2004, the NIHB Program will no longer provide reimbursement for Darvon© and 642© (propoxyphene) as exceptions. Darvon© and 642© will become exclusions to the Program, and as such, requests are not subject to appeal. Effective immediately, new requests are no longer being approved by the NIHB Drug Exception Centre. Patients, who have received Darvon© or 642© in the past 12 months will have their requests approved until June 1st, 2004, in order to allow time for reassessment and to plan for alternative therapy.

Band #458 -- Bigstone Cree Nation

The Bigstone Health Commission assumed complete management of pharmacy benefits on behalf of the members of Bigstone Cree Nation (Band #458) on February 1, 2004. This means that claims and prior approvals with a date of service (DOS) on or after April 1, 2003, must be submitted to Bigstone Health Commission. Claims submitted to FCH with a DOS on or after April 1, 2003, will be rejected with the message R30 (Client has alternative coverage. Contact FNIHB). Claims with a DOS prior to April 1, 2003, must be submitted to FCH and will be processed as usual. Predeterminations with a DOS prior to April 1, 2003, must be sent to FNIHB. Bigstone Health Commission's contact information is:

Attn: Mabel Gladue
Bigstone Health Commission
P.O. Box 1590
Wabasca, AB T0G 2K0
Phone: (780) 891-4161
Toll Free: 1-866-891-9719
Fax: (780) 891-3222

Supporting Documentation

Providers are reminded to keep appropriate documentation in support of each claim for two years from the date a prescription is dispensed. For refills, the original prescription must be kept on file for a period of two years after the most recent dispense date. Claims without supporting documentation may be recovered through the audit program. This applies to all paid claims, including those with prior approvals.

For further information on the Pharmacy Audit Program, please refer to Section 5.12 of the NIHB Pharmacy/MS&E Provider Information Kit.

Change of Ownership

When a pharmacy changes ownership, the pharmacy number under which the business is registered cannot be used by the new owner(s) to submit claims. This applies even if the name of the pharmacy remains the same. Instead, the pharmacy number must be end dated and the new owner(s) must complete their own Pharmacy/MS&E Provider Agreement. Once the Agreement has been approved, the pharmacy will be assigned a new provider number to be used for billing.

To obtain a copy of a Pharmacy/MS&E Provider Agreement, please contact the FCH NIHB Toll-Free Inquiry Centre at 1-888-511-4666.

Prescriptions and Claims for Multiple Family Members

Prescribers and pharmacists must ensure that a separate prescription is issued to each member of the family for the reimbursement of claims submitted under the NIHB Program. This includes products such as Nix® and Kwellada®. Separate claims must be submitted for each client using the client's own unique client identification number, and prescription number. This is to ensure accurate patient drug profiles.

Definition of Compounds

To facilitate the submission and payment of NIHB claims for extemporaneous mixtures, please note that the following definition applies:

"Extemporaneous mixtures are products that require compounding in a pharmacy in accordance with the orders of a prescriber and which must not duplicate the form-ulation of commercially manufactured drug products."

Extemporaneous mixtures which contain ingredients which are excluded from the NIHB Program will not be covered. The following is a list of some of the excluded ingredients:

• hair growth stimulants e.g., minoxidil in topical
• preparations
• fertility and impotence drugs e.g., alprostadil (Caverject)
• homeopathic preparations
• herbal remedies
• cosmetics

As a reminder, please be advised that extemporaneous mixtures containing exception or limited use drugs must be prior-approved by the NIHB Drug Exception Center (DEC). Upon contacting DEC, an analyst will gather the necessary details, including extemporaneous mixture pseudo-DIN and pricing information, in order to set up a prior approval.

Once approved, a second item line will be added to the NIHB Prior Approval Confirmation Letter that lists the DIN of the exception or limited use drug included in the mixture. This second item line is of no concern to the pharmacy when billing and is only being recorded for information and audit purposes. No dollar values are associated with this item line.

Upon receipt of the NIHB Prior Approval Confirmation Letter, the pharmacy may proceed with billing using the Extemporaneous Mixture pseudo-DIN, referencing the prior approval number provided. Claims submitted for extemporaneous mixtures containing exception or limited use drugs without a prior approval number will be subject to reversal.

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