Sample Pharmacy Claim Statement
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Pharmacy 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 Pharmacy Claim Statement.
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