Non-Insured Health Benefits (NIHB) Newsletter

For our Medical Supplies and Equipment Suppliers Fall 2004

News And Information For Our NIHB Providers
NIHB Toll-free Inquiry Centre: 1-888-471-1111

News and Views

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 1-888-471-1111 , or send your correspondence to:

FCH Provider Relations 3080 Yonge Street, Suite 3002 Toronto, ON M4N 3N1

Mandatory Prescription (rx) Information

Prescriptions submitted to FNIHB Regional Offices for prior approval, or retained on file, must contain the following mandatory information:

• Rx must be dated (a fax date is not acceptable as the prescription date)
• Rx must be signed by the prescriber in pen (a stamped prescriber signature is not acceptable)
• Rx must contain the full client given name and surname
• Rx must contain the item(s) and quantity prescribed [For some MS&E claims, this may not be possible as the physician is requesting that another health care professional assess the client (mobility, hearing, etc.). In such cases, the Rx must contain the physician's reason for the requested assessment.]

The original or faxed (see article below) prescription must be kept in the client's file for audit purposes. The absence of the original or faxed prescription in the client's file during an on-site audit will result in the recovery of the claim(s) associated with the prescription.

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.

Item Cost

Providers are reminded that the amount entered in the "Item Cost" field on the NIHB MS&E Claim Form must be the total acquisition cost for all units of the item dispensed, not the individual unit cost of the item dispensed.

For additional information on the data elements required on the NIHB MS&E Claim Form , please refer to Section 7.5 of the NIHB MS &E Provider Information Kit .

Claims Correction Procedure

The NIHB MS&E Claim Statement must be used to make corrections to claims rejected due to incorrect or missing information on the original claim submission. Providers must also use the statement to request FCH to reverse the amount paid for benefit items that have not been picked up by the client or 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 1-888-471-1111 .

Prescriber ID

Providers are reminded that the "Prescriber" field cannot be left blank on the NIHB MS&E Claim Form . It must be completed with either the prescriber's License Number or Provincial/Territorial Billing Number, or the prescriber's name.

Claims submitted with a blank "Prescriber" field will be rejected with the message R14 (INSUFFICIENT BENEFIT INFORMATION TO ADJUDICATE CLAIM ).

For additional information on the data elements required on the NIHB MS &E Claim Form , please refer to Section 7.5 of the NIHB 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 MS&E Claim Form is a mandatory field, therefore claims submitted for repair labour and replacement parts must be submitted with '999Repair' entered in the "Prescriber" field. Claims for repairs submitted without '999Repair' will be rejected with the message R14 (INSUFFICIENT BENEFIT INFORMATION TO ADJUDICATE CLAIM ).

Next Day Claims Verification (NDCV) Program

The NDCV Program is an ongoing process consisting of a review of a sample of claims the day following receipt by FCH. Audits are conducted to confirm that claims are being properly submitted and documented.

Providers will receive an MS&E Faxback Confirmation Form C asking them to describe the clinical circumstances and services provided on the date of service noted on the form. Providers must complete the form and return it within 2 weeks of the date of receipt. If the form is not returned within 2 weeks, the claim is reversed. Forms returned within the timeframe indicated will be evaluated by the audit team to determine if the information provided is consistent with the item codes claimed. Item codes and defined code descriptions are not accepted as a sufficient response. Inconsistencies or lack of information will result in the claim being reversed, or reversed and reprocessed for a lower amount, to bring payment into line with NIHB guidelines. Monies will be deducted from your NIHB MS&E Claim Statement as a claim reversal. Claims with prior approvals are also subject to this process.

For additional information on the NIHB MS&E Provider Audit Program, please refer to Section 3 of the NIHB MS&E Provider Information Kit.

Providers can download a current version of the NIHB 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 1-888-471-1111 .

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