Non-Insured Health Benefits Newsletter

First Canadian Health

News and Information for our NIHB Providers

NIHB Toll-free Inquiry Centre: 1-888-471-1111

For our Medical Supplies and Equipment Suppliers

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

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

Frequency Limit for Disposable Diapers and Briefs

The information below clarifies what is found in Section 4.5.2 of the MS&E Provider Information Kit (MPIK).

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 MS&E 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 the item code is NIHB eligible by referring to the NIHB Medical Supplies and Equipment (MS&E) Provider Information Kit (MPIK). Only item codes that are listed in the MPIK 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 claimant identification information.

If the client, however, is not registered as an NIHB client, the claimant must do so before 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 item is eligible under the NIHB Program. This includes cases where the item code on the claim is invalid. The following information must be provided on each claim:

• Date of Service
• Quantity
• Item Code
• Item Cost
• Prescription Number
• Prescriber ID

Providers must check the claim for missing, incomplete or incorrect information, and provide the required information as outlined in Sections 7.5 and 7.8 of the NIHB Medical Supplies and Equipment (MS&E) Provider Information Kit (MPIK). Additional benefit information is provided in Section 2 of the MPIK.

R49 Benefit requires prior approval

The claim has not been paid because it requires prior approval from FNIHB. The MS&E benefit lists in the MPIK identify the item codes that require prior approval (PA). Providers must obtain a PA from the appropriate FNIHB Regional Office. The PA number must be indicated on the claim submission.

Providers can download a current version of the NIHB Medical Supplies and Equipment Provider Information Kit at the NIHB website at:

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

Providers without internet access can contact the FCH NIHB Toll-Free Inquiry Centre at 1-888-471-111.

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