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 in Quebec

Summer 2005

News and Views

Welcome to the summer 2005 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

Summer 2005 NIHB Drug Benefit List Update

Please find attached the summer 2005 updates, which list all changes to the April 1 st , 2005 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 July 1 st , 2005.

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

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

Notification on the Transfer of the NIHB Drug Exception Centre (DEC)

In early Fall 2005, the NIHB Drug Exception Centre (DEC), which is currently managed by the Ontario Regional Office, will be transferred to the NIHB Directorate at headquarters in the National Capital Region. The toll-free telephone and fax numbers will remain the same. Providers will receive further details regarding this change at a later date.

Wound Dressing Supplies

Providers are reminded that when sending claims for dressings, adhesive tapes, and bandages, they must use the item codes listed in Section 10.B.2.5 of the Pharmacy/Medical Supplies and Equipment (MS&E) Provider Information Kit .

New Agreement with AQPP

Health Canada and the Association Québécoise des Pharmaciens Propriétaires (AQPP) have agreed on a new pricing structure for pharmacy providers in Quebec. The highlights of the agreement are as follows:

• Item categories that had a tolerance fee of 10% now have a markup fee of 7.15%
• Methadone no longer requires special authorization.
• Dispensing fees have increased from $8.00 to $9.00
• Extemporaneous mixture fees have increased to $12.52
• Dosette fees have increased to $4.50
• Fees have increased to $3.46 for Diabetic syringes supplies.
• The tolerance fee of certain MS&E items submitted by pharmacy providers have increased to 43%
• Pharmacy providers will be submitting the revised NIHB General Medical Supply and Equipment Prior Approval Form to the FNIHB Regional Office for prior approval requests for MS&E items.

For more details on the new pricing structure, please refer to the notice sent by the AQPP, regarding the agreement. Should you experience difficulties submitting claims with the new pricing structure, please contact your software vendor. For general claims submission or billing issues, please contact the FCH NIHB Toll-Free Inquiry Centre at 1-888-511-4666.

Methadone for Opioid Dependency, Pseudo-Din 00908835

A new policy has been implemented in Quebec for the submission and reimbursement of methadone for the treatment of addictions.

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 .

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 that is 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.

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.

Prior Approval Requests for MS&E Items

Prior approval requests for MS&E items can only be obtained from the FNIHB Regional Office. Please refer to the Directory insert in the pocket of your NIHB Pharmacy/Medical Supplies and Equipment (MS&E) Provider Information Kit (PPIK) for the telephone number and address of each FNIHB Regional Office.

Pressure Garments and Pressure Orthotics

The information below clarifies what is found in Section 10B.5.2 of the Pharmacy/MS&E Provider Information Kit (PPIK).

Only a physician can prescribe a graduated compression stocking/Sleeve (20-30, 30- 40 mm Hg), burn scar pressure garment, burn orthosis, and extremity pumps.

Compression garments above 40 mm Hg require a prescription from one of the following specialists:

• Vascular Surgeon
• Orthopedic Surgeon
• Radiation Oncologist
• Medical Oncologist
• Internist
• Paediatrician
• Plastic Surgeon
• Physiatrist
• General Surgeon
• Dermatologist
• Thrombologist

Only a recognized provider (or an employee of this provider) who has certification as a compression garment fitter can provide compression garments and extremity pumps.

Only a recognized provider (or an employee of this provider) who has certification as a compression garment fitter for burn and scar management , an occupational therapist, physiotherapist, prosthetist, orthotist, and a prosthetist/orthotist (member of the CBPO) who has expertise in the field can provide burn scar management (pressure orthotics).

Rejected Claims

First Canadian Health (FCH) is committed to ensuring that providers receive prompt payment of their NIHB claims. Many claims are rejected during adjudication due to avoidable submission errors. This leads to delays in the payment of claims.

FCH has determined that the most frequent reasons why claims are rejected on the NIHB Pharmacy Claim Statement are:

R04 This is not an Eligible Benefit

The claim has not been paid because the item is not covered under the NIHB Program.

Providers can verify if a drug or MS&E item code is eligible under the NIHB Program by referring to the NIHB Drug Benefit List (DBL) or Section 10 of the NIHB Pharmacy/Medical Supplies and Equipment (MS&E) Provider Information Kit (PPIK). Only item codes that are listed in the NIHB DBL and PPIK are eligible under the NIHB Program.

R05 Claimant Could not be Verified as an NIHB client

The client verification problem may be due to:

• The claimant has not used his or her registered surname, given names or date of birth; or
• The claimant has made an error in specifying the client identification number.

In such cases, it may only be necessary for the client to provide more accurate client identification information.

If the client, however, is not registered as an NIHB client, the claimant must do so before the services can be provided. For further information, please contact the FNIHB Regional Office.

R14 Insufficient Benefit Information to Adjudicate Claim

The claim did not provide sufficient information to determine if the claimed drug or MS&E item code is eligible under the NIHB Program. This includes cases where the DIN or a drug or MS&E item on the claim is invalid. The following information must be provided on each claim:

• Date of Service
• Quantity
• Days Supply
• DIN or Item Code
• Drug/Item Cost
• Prescription Number
• Prescriber ID

The provider must check the claim for missing, incomplete or incorrect information, and provide the required information as outlined in Section 5.6 of the NIHB Pharmacy/Medical Supplies and Equipment (MS&E) Provider Information Kit (PPIK). Additional benefit information is provided in Section 2 of the PPIK.

R49 Benefit requires prior approval

The claim has not been paid because it requires prior approval from FNIHB. The NIHB Drug Benefit List and the MS&E benefit lists in the MPIK identify the item codes that require prior approval (PA). You must obtain a PA from the appropriate FNIHB Regional Office for MS&E items, or the NIHB Drug Exception Centre for drug items. The PA number must be indicated on the claim submission.

Providers can download a current version of the NIHB Pharmacy/Medical Supplies and Equipment Provider Information Kit and Drug Benefit List (DBL) from the NIHB website at:

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

If you don't have internet access, please 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