Non-Insured Health Benefits (NIHB) Newsletter for Pharmacy Providers
- Winter 2005-2006
News and Information for our NIHB providers
NIHB toll-free inquiry centre: 1-888-511-4666
For Our Pharmacy Providers - Winter 2005-2006
News and Views
Welcome to the Winter 2005-2006 edition of the Non-Insured Health
Benefits (NIHB) quarterly newsletter. First Canadian Health (FCH) is
now in its seventh 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
Winter 2005-2006 NIHB Drug Benefit List Updates
Please be advised that the NIHB Drug Benefit List Updates are not included
with this Newsletter. The NIHB Drug Benefit List Updates will be available
on the NIHB Website on January 1, 2006.
The January 1, 2006 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.
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/fnih-spni/pubs/nihb-ssna_e.html
Should you have any questions, please contact the FCH NIHB Toll-Free
Inquiry Centre at 1-888-511-4666.
Removal of the R14 Edit for Point of Service (POS)
Claims
On November 18, 2005, the rejection message R14 Insufficient
Benefit Information to Adjudicate Claim will no longer be transmitted
to providers on the provider statement for POS claims. Claims that are
missing any of the following data elements: date of service, DIN/item number,
prescriber Id, prescription number, drug/item cost, quantity, or days supply
will be rejected through POS with the appropriate existing Canadian Pharmacists
Association (CPhA) code (A2, 22, 53, 55, 56, 58, 59, 61 or 66), and the
corresponding message.
Should you have any questions, please contact the FCH NIHB Toll-Free
Inquiry Centre at 1-888-511-4666.
NIHB Drug Exception Centre Address Change
The offices of the NIHB Drug Exception Centre will be moving the weekend
of November 11-13, 2005, to the Graham Spry Building in Ottawa, and
will be open for regular operations on Monday, November 14, 2005.
Effective November 14, 2005, the NIHB Drug Exception Centre's address
on Prior Approval Confirmation letters and the Level One appeals will
change to:
NIHB Drug Exception Centre
First Nations and Inuit Health Branch
Health Canada
Graham Spry Building
250 Lanark Avenue
6th Floor, Postal Locator 2006B
Ottawa, ON K1A 0K9
All toll-free phone and fax numbers will remain the same.
Should you have any questions, please call the NIHB Drug Exception Centre
at 1-800-580-0950.
Implementation of the New Warning Message NE (Potential
Overuse/Abuse Indicated)
As of December 16th, 2005, a new warning message, NE
(Potential Overuse/Abuse Indicated), will be used by the NIHB
Program. This warning code will not prevent the payment of claims,
but will provide pharmacists with additional information citing a potential
drug entity misuse/abuse situation.
The CPhA warning message "Potential Overuse/Abuse Indicated" will
be returned for POS claims that meet the following criteria:
- 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 opioid narcotic drug entities.
- Use of three (3) or more different benzodiazepine drug entities.
- Use of a combination of three (3) or more opioid narcotics drug entities
and three (3) or more benzodiazepines drug entities.
In all of these cases, the NE warning code will appear on the NIHB
Pharmacy Claim Statement, but the corresponding message will not appear
on the statement.
Should you have any questions, please contact the FCH NIHB Toll-Free
Inquiry Centre at 1-888-511-4666.
Changes in Reimbursement for Proton Pump Inhibitors
(PPIs)
On October 1, 2005, the NIHB Program changed the formulary status and
availability of selected PPI's. Details on this policy can be found in
the September 2005 NIHB Drug Bulletin. Available evidence indicates that
these agents have the same clinical effect; there will be few exemptions
to this new policy.
Implementation of this policy has been phased in, beginning with
new prescriptions, on October 1, 2005. For renewal requests, the
NIHB Program will only authorize PA's until February 1, 2006. After
this time, all requests must follow the new PPI policy.
In cases where pharmacy providers have active prior approvals which
extend beyond February 1, 2006, the Program will honour these PA's until
they have been exhausted. After this time, all requests must follow the
new PPI policy.
The NIHB Program has been faxing letters to all PPI prescribers advising
them of the Program's new policy in order to allow adequate time for
reassessment and to plan for alternative therapy.
The New PPI Policy
The new limited use criteria for PPIs is: Lansoprazole 15 and 30mg (Prevacid®),
Omeprazole 10 and 20mg (Losec®), Omeprazole Magnesium 10 and 20mg
(Losec®), and Pantoprazole 40mg (Pantoloc®) will only be available
as limited use benefits after patients have been tried for at least 60
days on Apo-Omeprazole® 20mg AND for at least 60 days on a therapeutic
dose of Pariet® 10mg (for example, two tabs daily).
In addition, as a result of this policy change, Esomeprazole 20mg and
40mg (Nexium®), Pantoprazole 20mg (Pantoloc®), and Rabeprazole
20mg (Pariet®) will no longer be reimbursed by the NIHB Program.
Should you have any questions, please contact the FCH NIHB Toll-Free
Inquiry Centre at 1-888-511-4666.
Item Cost Field
The amount entered in the "Item Cost" field on the NIHB Pharmacy
Claim Form must be the total acquisition cost of all units of
the item dispensed for the claim. In other words, the amount in the "Item
Cost" field represents the quantity dispensed, multiplied by the unit
cost of the item. Failure to enter the correct amount in this field
will result in claims being returned unprocessed to the providers.
For additional information, please refer to Section 5.8 of the NIHB
Pharmacy/MS&E Provider Information Kit.
Methadone for Opioid Dependency, pseudo-DIN 00908835
A new policy was implemented on October 1, 2003 for the submission and
reimbursement of methadone used for the treatment of addictions in all provinces and territories.
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 for opioid dependency.
Claims must be submitted once a week (every seven days) at the
end of the week. In Ontario, claims will continue to be submitted
daily to comply with legislation.
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
is not allowed to 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.
NIHB Pharmacy Provider Audit
Providers are reminded that under the NIHB Provider Audit Program, incorrect
claim submissions are resulting in audit recoveries. We are sharing these
findings for clarification purposes, to assist the pharmacist in complying
with the terms and conditions of the NIHB Program.
Reversals for Prescribed Medication Not Picked Up by Clients
The "Claim Reversal" transaction is used to reverse a previously submitted
and paid POS transaction. Providers need to reverse a previously submitted
claim when the item has not been picked up by the client, with the exception
of extemporaneous mixtures.
For further information, please refer to section 5.6 of the NIHB Pharmacy/MS&E
Provider Information Kit.
Quantity for Nix Cream Rinse 1%®
The quantity limitation for Nix Cream Rinse 1%® is
56 grams (or multiples thereof). Claims submitted in excess of 56 grams
(or multiples thereof) that have resulted in a drug cost overpayment
will be recovered through the Audit Program.
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.
Please refer to the Fall 2004 NIHB Newsletter.
Prescription Not Found on Site
As per provincial regulations and NIHB Program requirements, providers
must retain the original or faxed prescriptions for review during an
on-site audit, for all prescriptions being dispensed against. Faxed prescriptions
must include the mandatory transmission information (which includes the
date sent and the sender's information) in order to be valid. The prescriptions
therefore, should not be cut to fit the Rx cases.
In conclusion, the absence of the original or faxed prescription in
the client's file during an on-site audit will result in the recovery
of claim(s) associated with the prescription.
Discrepancies in the quantities (Monistat 3 Dual Pack)
Audit findings have identified situations where the quantity recorded
on the claim does not match the quantity of the prescription. For example,
the provider has submitted a quantity of three (3) packs for a three
(3) day supply, rather than one (1) pack for a three (3) day supply.
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 can be accessed at the
following NIHB
website:
www.hc-sc.gc.ca/fnih-spni/nihb-ssna/benefit-prestation/drug-med/index_e.html
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 NIHB Program requirements.
Appeal Process
When a client is denied a benefit, there are three levels of appeal
available under the NIHB Program. Providers are reminded that appeals
can only be initiated by the client, or with written confirmation that
the client is aware that the appeal is being submitted on his/her behalf.
Appeals submitted by providers without client confirmation, will not
be subject to review.
Coordination of Benefits with the Ontario Drug Benefit
(ODB) Limited Use List (for Ontario Pharmacies Only)
Physicians are no longer required to use the ODB Limited Use (LU) prescription
form. The LU code may be written on a regular prescription for LU drugs.
Providers can download the new NIHB
Pharmacy/Medical Supplies and Equipment Provider Kit dated
September 2005 at the following NIHB website:
www.hc-sc.gc.ca/fnih-spni/pubs/drug-med/2005_kit-trousse_info/index_e.html
Providers without internet access can contact the FCH NIHB Toll-Free Inquiry Centre at 1-888-511-4666.
Published quarterly by First Canadian Health
Management Corporation Inc. at 3080 Yonge Street, Suite 3002, Toronto
ON M4N 3N1
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