Non-Insured Health Benefits (NIHB) Newsletter for Pharmacy Providers - Fall 2005

News and Information for our NIHB providers

NIHB toll-free inquiry centre: 1-888-511-4666

For Our Pharmacy Providers - Fall 2005

• Fall 2005 NIHB Drug Benefit List (DBL) Updates
• New Drug Utilization review (DUR) Warning Message NE - Potential Overuse/Abuse Indicated
• Documentation for Overriding Rejected Claims
• Appeal Process

Fall 2005 NIHB Drug Benefit List (DBL) Updates

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, 2005.

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

www.hc-sc.gc.ca/fnih-spni/pubs/drug-med/drug-med_list/index_e.html

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

New Drug Utilization review (DUR) Warning Message NE - Potential Overuse/Abuse Indicated

By the end of 2005, the DUR information returned to the provider will include the Canadian Pharmacists Association (CPhA) response code NE, which indicates potential overuse/abuse of specified drug entities. The warning code will not prevent the payment of claims, but will provide pharmacists with additional information concerning potential problems related to the current drug claim. The new warning code and message will be sent to providers for claims that meet the criteria below:

• 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 narcotic drug entities.
• Use of three (3) or more different benzodiazepine drug entities.
• Use of three (3) or more narcotic drug entities and three (3) or more benzodiazepine drug entities.

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

Documentation for Overriding Rejected Claims

Currently, claim submissions which generate the following messages during Drug Utilization Review (DUR) - termed Drug Use Analysis (DUA) in Quebec - are rejected:

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

Following a review and, based on his/her professional judgment, the provider can override the rejection by re-submitting the rejected claim with a valid CPhA intervention code.

In the Fall 2001 Newsletter, the NIHB Program specified that, for each of these interventions, providers must complete and retain appropriate documentation. This may be documented either directly on the prescription or on any hard copy or electronic version of the patient profile. The Newsletter article also indicated that the information was to be available for review, if required, during the claims verification/auditing process.

Lack of documentation of DUR overrides continues to be a significant audit finding. Therefore, providers are reminded that interventions which lack supporting DUR documentation, are subject to reclaim.

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.

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