Vision Care Framework

Prior Approval Process

To ensure that reimbursement for goods and services is rendered providers must obtain a prior approval (PA) from the NIHB Regional Office. If prior approval is granted, a PA number will be provided for billing purposes. Only then should the provider proceed with the fabrication/fitting/dispensing of the item. In applicable regions, Professional/Dispensing fees will be authorized in accordance with the relevant NIHB Program regional payment schedule. The PA will also ensure efficient processing of the claim.

If the client resides in a remote area, delivery charges (including mailing and registration) may be paid by the regional office. Request for payment for any delivery charges should be included in the request for prior approval.

Prescribers and providers should contact the Regional Office in the province or territory where they practice for additional information on the PA process.

Eye and Vision Examinations

General Eye and Vision Examination (Full, Major, Routine)
(Only in Applicable Regions)

General eye and vision examinations are benefits to the NIHB Program when performed by an ophthalmologist or an optometrist in those regions where the eligible First Nations and Inuit client is not covered by provincial, territorial, private or other federal health care plans.

The general examination must include all of the following:

• case history
• external examination of the eye
• assessment of visual acuity
• profile of ocular motility
• objective and subjective measurement of refraction
• assessment of binocular coordination
• assessment of amplitude of accommodation, when required
• biomicroscopy and assessment of pupillary reflexes
• tonometry (if clinically indicated)
• direct ophthalmoscopy
• analysis and diagnosis of findings
• recommendations to the patient and, if necessary, prescription for treatment

Specific Examination (Only In Applicable Regions)

Clients may be eligible for coverage from the NIHB Program when a severe abnormality in their ocular or visual condition requires a thorough assessment using specific tests. This condition will have been detected at the general examination. Specific examinations will be performed by an ophthalmologist or an optometrist who must be able to attest in writing to the oculo-visual condition justifying the examination.

Specific examinations include at least one of the following tests:

• assessment of visual fields, using a Goldmann perimeter/visual field analyzer
• color blindness vision test
• examination of the peripheral retina under pupil dilation
• study of oculomotor imbalance using the Hess-Lancaster test
• study of contrast sensitivity function over at least six spatial frequencies
• measurement of aniseikonia using an eikonometer or afocal magnifying lenses
• precise assessment of visual impairment and trial of optical aids
• assessment of corneal topography using a computerized video-keratoscope
• trial contact lens and assessment of ocular reaction for eligible clients
• electroretinogram measurement or visually evoked potentials

Follow-Up Examination (Control, Minor) (Only In Applicable Regions)

Clients may be eligible for a follow-up examination when their ocular or visual condition requires one. The examination will be performed by an ophthalmologist or an optometrist who must be able to attest in writing to the oculo-visual condition justifying the examination. Authorization will be granted only if the client is not eligible for a general examination.

The follow-up examination must include all of the following:

• case history
• the repetition of one or more tests from the general examination in order to assess the condition or progression of the oculo-visual condition
• diagnosis
• recommendations to the patient and, if necessary, prescription for treatment.

Frequency Guidelines

• Eye and Vision Examinations
  • Eye/vision exam, general (full, major, routine) -- if eligible NIHB client is not covered by provincial, territorial, private or other federal health care plans
• Frequency Guidelines
  • Under 18 years old - 1 per year 18 years old and over - 1 per 2 years
    
• Eye and Vision Examinations
  • Eye/vision exam, follow-up (control, minor exam) -- if eligible NIHB client is not covered by provincial, territorial, private or other federal health care plans
• Frequency Guidelines
  • Evaluated on a case by case basis
    
    
• Eye and Vision Examinations
  • Eye/vision exam, specific examination -- if eligible NIHB client is not covered by provincial, territorial, private or other federal health care plans
• Frequency Guidelines
  • Evaluated on a case by case basis