Vision Care Framework
Appeal Procedures
There are three levels of appeal available under the NIHB Program which must be initiated by the client in writing. At each stage, the appeal must be accompanied by supporting information from the prescriber or provider; therefore, it is important that all of the following information be included along with the client's letter:
- The condition (diagnosis and prognosis) for which the item or service is being requested
- Alternatives that have been tried
- Relevant diagnostic test results
- Justification for the proposed benefit or service.
The appeal will be reviewed by a qualified health care consultant who will provide a recommendation to NIHB. The final decision will be made by NIHB, based on the consultant's recommendation, client's specific needs, the availability of alternatives, and NIHB policy.
Information sheets outlining the three levels of appeal and the contact addresses are available from the First Nations and Inuit Health Branch Regional Offices or on the NIHB Web Site.
Appeals cannot be submitted for any exclusions under the NIHB Program.
Exclusions are goods and services which will not be provided as benefits under the NIHB Program under any circumstances and are not subject to the NIHB appeal procedures.
Exclusions include:
- vision care goods and services covered by the provincial/territorial insurance plan in the province/territory of residence of the client; or any other third party
- additional carrying cases for glasses or contact lenses (one is usually dispensed with the initial purchase)
- cleaning kit
- esthetic products
- shampoo (e.g. "no more tears" type shampoo solution)
- a vision examination in the following cases: to obtain a job, driver's license or to engage in sports activity
- a vision examination at the request of a third party (for example: completing a report or medical certificate)
- contact lenses for esthetic purpose
- contact lens solution
- industrial safety frames or lenses for sports or professional use
- progressive, or trifocal lenses
- photochromic/photochromatic lenses
- sunglasses with no prescription (please refer to the "Tints and Coating for Lenses" section to verify when tints may be authorized for prescription glasses)
- replacements as a result of misuse, carelessness or client negligence
- implants (e.g. punctal occlusion procedure)
- refractive laser surgery
- treatments with investigational/experimental status
- vision training
NIHB Provider Audit Program
NIHB reserves the right to undertake ongoing quality assurance and audit activities on claims submitted under the NIHB Program. These activities are required to comply with accountability requirements for the use of public funds and to ensure provider compliance with the terms, conditions and prices of the program.
The objectives of the NIHB Provider Audit Program are to:
- validate the active license of the provider, if applicable
- validate the credentials of the provider, if applicable
- detect billing irregularities, whether through error or fraudulent claims
- ensure that the services paid for were received by the NIHB client
- ensure that any required signatures on claim submissions are valid
- ensure that providers have retained appropriate documentation in support of each claim, in accordance with the terms and conditions of the program.
The audit activities are based on accepted industry practices and accounting principles and may be carried out up to a maximum of two years from the date of service. Providers must retain a copy of the original prescription in accordance with provincial or territorial requirements, and any other information to support a claim on file for two years from the date of dispense for audit purposes. Claims for which the original prescription or supporting documentation is not available for review, including those with prior approvals, may be recovered through the audit program. A unique prescription number must be assigned by the provider for each item dispensed and claimed.
Hard copy and electronic patient records are reviewed where documentation is required (documentation of Drug Utilization Review overrides, therapy change, etc.)
The provider must maintain records relating to NIHB clients and their prescriptions in accordance with all applicable laws. All records shall be treated as confidential so as to comply with all applicable provincial and federal legislation regarding confidentiality of patient records.
A provider submitting claims under the NIHB Program will assist NIHB, or a third party authorized by NIHB by:
- granting access to provider's premises, during the provider's normal business hours, to inspect, review and reproduce any vision records maintained by the provider pertaining to NIHB claims
- providing access to all documentation relevant to the processing and payment of vision care claims, held by the service provider to Health Canada, its agents or contractors, or any appropriate health professional licensing or regulatory body for the purposes of administrative audit, including original prescriptions and cancelled or revoked prescriptions
- responding to a request for documentation via mail or fax within the specified response time
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