Medical Supplies and Equipment (MS&E) Claim Statement
Medical Supplies and Equipment Claim Statement
Date Of Service
Claims are presented on the statement in order of date of service
(oldest date first).
Prescription No.
Claims with the same date of service are presented in order
of prescription number.
Client Information
The information includes Client ID No., Surname, Given Names,
and Date of Birth. The client information on the statement is based on
the NIHB client list. Warning messages are shown for claimants who have
been accepted as NIHB clients on a temporary basis only (unregistered
infant) and for claims submitted on paper claim forms. Where client-identification
information corrections have been made, a W14 message is indicated. Please
use the corrected client identification information on future claims
to expedite client verification.
Band No. and Family No.
These fields refer to the claimant's band number and family
number (sometimes called a treaty number).
Doc/Inv. No
This field refers to the NIHB Health Information Claims Processing
System (HICPS) system-number, generated for each claim.
Prescriber No.
This field refers to the prescriber number as entered by the
provider on the claim submission, which must be the same as required
by the provincial/ territorial pharmacare program.
- British Columbia Physician License Number
- Alberta Physician License Number
- Saskatchewan Physician's Provincial Billing Number
- Manitoba Physician License Number
- Ontario Physician License Number
- Quebec Physician License Number
- New Brunswick Physician's Provincial Billing Number
- Nova Scotia Physician License Number
- Prince Edward Island Physician License Number
- Newfoundland Physician License Number
- Yukon Physician's Territorial Billing Number
- Northwest Territories Physician License Number
- Nunavut Physician License Number
Approval No.
This field is valued only for those items for which an FNIHB
prior approval was provided.
DIN/Item Code
This field indicates the Drug Identification Number (DIN) or
item code.
Quantity
This field indicates the quantity (number of units) of the item
dispensed.
Drug/Item Cost
The total ingredient or acquisition cost for all units of the
drug or item dispensed.
Dispensing Fee
The dispensing fee for the item dispensed.
Mark-Up
The dollar amount of any mark-up for the item, based on the
percentage.
Third Party
The dollar amount of any portion of the claim billable to a
provincial or territorial program or other third party.
Amount Claimed
The sum of the drug-item cost, dispensing fee and mark-up for
the item.
Net Amount
This field shows the net payable amount.
Grand Total Paid
This field shows the grand total paid on the final page of the
MS&E Claim Statement.
List Terminology:
Field Name:
The name of the field, corresponds to the field on the
claim form.
Length:
The field length specification for claims submitted on
computer printouts or diskettes.
Description:
A brief description of the data element. |
Fields marked with an asterisk (*) are mandatory.
Field Name: *Client Surname
Length : 30
Description : The surname under which the client is
registered.
Field Name: **Client Given Name
Length : 30
Description : The given name(s) under which the client
is registered. Submission of more than one given name is preferred to
facilitate client verification. Initials are not acceptable.
Field Name : *Client Date Of Birth (DD/MM/YYYY)
Length : 8
Description : The full birth date in dd/mm/yyyy format
(For example, 13/05/1992 represents 13 May 1992). Partial birth dates
are not acceptable.
Field Name : * Address /Apt/ City /
Length : Prov./Postal Code
Description : N/A
The current and exact address of the client.
Field Name : *Client Identification No.
Length : 10
Description : A unique number used to identify a client
who is eligible to receive benefits under the NIHB Program. This number
may be one of:
- a 9 or 10-digit number issued to eligible First Nations clients by
Indian and Northern Affairs Canada (INAC),
- an alpha prefix followed by an 8-digit number issued to certain
eligible First Nations and recognized Inuit clients by FNIHB, or
- an alpha prefix followed by a 7-digit health care number issued
to recognized Inuit by the Government of the Northwest Territories
or the Government of Nunavut.
Field Name : *Band No. (Not Applicable
To Inuit Clients)
Length : 3
Description : A 3-digit number (For example,, 002, 311)
identifying the band to which the client belongs. The band number, if
submitted in combination with the client's family number, is an acceptable
alternative to the client identification number for an eligible First
Nations client.
Field Name : *Family No. (Not Applicable
To Inuit Clients)
Length : 5
Description : A 4 or 5-digit number (For example, 1041,
04120) identifying the family unit, within the band, to which a client
belongs. The family number, if submitted in combination with the client's
band number, is an acceptable alternative to the client identification
number. If the family number has fewer than 5 digits, please insert the
appropriate number of zeros in front of the number ( For example,
125 becomes 00125 ).
Data Element Descriptions -- Claim Information
for Each Prescribed Item
Field Name : Date Of Service (DD/MM/YYYY))
Length : 10
Description : The date on which service was provided
to the client, in dd/mm/yyyy format (for example, 13/05/1992 represents
13 May 1992).
Field Name : *DIN/Item Code
Length : 8
Description : The item code.
Field Name : *Quantity
Length : 5
Description: The quantity (number of units) of the item dispensed.
Field Name : *Prescription No.
Length : 9
Description : The prescription number assigned by the
MS&E provider for the item dispensed.
Field Name : *Item Cost
Length : 6
Description : The total acquisition cost for all units
of the item dispensed.
Field Name : Dispensing Fee
Length : 6
Description : The dispensing fee for the item. Leave
blank if not applicable.
Field Name : Markup
Length: 6
Description: The dollar amount of any mark-up for the item, based on
the established percentage. Leave blank if not applicable.
Field Name : *Third-Party Share
Length : 6
Description : The dollar amount of any portion of the
claim which is billable to a provincial or territorial program or other
third party. Leave blank if not applicable.
Field Name : *Amount Claimed
Length : 6
Description : The sum of the item cost, dispensing fee,
and mark-up for the item, less any third-party share.
Field Name : Days Supply
Length : 3
Description : Estimate of the number of days of treatment
contained in the prescription.
Field Name : Total
Length : 6
Description : The total dollar amount claimed for all
items (up to 3) listed on the claim form.
Field Name : *Prescriber
Length : 10
Description : The prescriber number as entered by the
provider on the claim submission must be the same as required by the
provincial/territorial pharmacare program. Claims for repair labour and
replacement parts must be submitted with '999Repair' in the prescriber
field, or they will be rejected on the NIHB MS&E Claim Statement
with an R14 error (Insufficient Benefit Information
to Adjudicate Claim).
- British Columbia Physician License Number
- Alberta Physician License Number
- Saskatchewan Physician's Provincial Billing Number
- Manitoba Physician License Number
- Ontario Physician License Number
- Quebec Physician License Number
- New Brunswick Physician's Provincial Billing Number
- Nova Scotia Physician License Number
- Prince Edward Island Physician License Number
- Newfoundland Physician License Number
- Yukon Physician's Territorial Billing Number
- Northwest Territories Physician License Number
- Nunavut Physician License Number
Data Element Descriptions -- Medical
Supplies and Equipment Provider Information
Field Name : *Prior Approval No.
Length : 8
Description : An authorization number, which must be
issued by FNIHB before the provider dispenses certain drugs, medical
supplies and most medical equipment.
Field Name: *Provider/Supplier Name
Length : N/A
Description : The name of the provider/supplier submitting
the claim. May be formatted as determined by the provider/supplier.
Field Name: *Provider/Supplier Address
Length : N/A
Description : The address of the provider/supplier submitting
the claim. May be formatted as determined by the provider/supplier.
Field Name: *Provider/Supplier Number
Length : 10
Description : The number assigned to the provider/supplier
upon registration as an NIHB provider with FCH.
Parent Information (required for infants
under one year of age)
An infant under one year of age who does not yet have a client identification
number may receive benefits if one of the infant's parents can be verified
as an eligible client. In such a case, the infant's surname, all given
names, and the date of birth must be entered in the appropriate fields
in the Client Information section of the claim ( Note :
these claims may only be submitted using the Non-Insured Health Benefits
Medical Supplies and Equipment Claim Form), and this information about
the parent must be provided:
Field Name: *Parent's Surname
Length: 30
Description: The surname under which the parent is registered.
Field Name: *Parent's Given Names
Length: 30
Description: The given names under which the parent
is registered. Submission of more than one given name is preferred to
facilitate client verification. Initials are not acceptable.
Field Name: *Parent's Date Of Birth (DD/MM/YYYY))
Length: 8
Description: The parent's full birth date in day-month-century-year
format (for example, 13/05/1956 represents 13 May 1956). Partial birth
dates are not acceptable.
Field Name: * Address /Apt/ City / Prov./Postal Code
Length: N/A
Description: The current and exact address of the parent.
Field Name: *Parent's Client Identification No.
Length: 10
Description: The unique number under which the parent
is registered. This number may be one of:
- 9 or 10-digit number issued by Indian and Northern Affairs Canada
(INAC),
- 3-digit band number, immediately followed by the 4 or 5-digit family
number identifying the family unit within the client's band,
- An alpha prefix followed by 8 digit number issued to certain eligible
clients by FNIHB, or
- A health care number issued by the Government of the Northwest Territories
or Nunavut .
Field Name: *Parent's Band No. (N ot Applicable
To Inuit Clients)
Length: 3
Description: A 3-digit number (For example, 002, 311)
identifying the band to which the infant's parent belongs. The band number,
if submitted in combination with the family number, is an acceptable
alternative to the INAC client identification number.
Field Name: Parent's Family No. (N ot Applicable
To Inuit Clients)
Length: 5
Description: A 4 or 5-digit number (For example, 1041,
04120) identifying the family unit, within the band, to which the infant's
parent belongs. The family number, if submitted in combination with the
band number, is an acceptable alternative to the INAC client identification
number. If the family number has fewer than 5 digits, please insert the
appropriate number of zeros in front of the number.
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