1.0 General policies
Effective date: September 27, 2024
These are the general policies of the Indigenous Services Canada (ISC) Non-Insured Health Benefits (NIHB) Medical Supplies and Equipment (MS&E) benefits for eligible First Nations and Inuit. Use the general policies in combination with specific policies found within the guide and benefit lists in sections 2.0 to 13.0.
Table of contents
- 1.1 Introduction
- 1.2 Information for clients
- 1.3 Client eligibility
- 1.4 Providers with MS&E specialties
- 1.5 Terms and conditions of services
- 1.6 Types of MS&E benefits
- 1.7 Prescription requirements for MS&E items
- 1.8 Prescriber/recommender requirements
- 1.9 Prior approval process
- 1.10 Special authorization
- 1.11 Coverage of supplies, maintenance, and repairs of medical equipment covered by another benefit plan or purchased by the client
- 1.12 Recommended replacement guidelines
- 1.13 Rentals
- 1.14 Repairs
- 1.15 Warranties
- 1.16 MS&E claims submission and provider payment policies (effective Spring 2025)
- 1.17 Client reimbursement
- 1.18 Coupons and discounts
- 1.19 Coordination of benefits
- 1.20 Balance billing
- 1.21 Unclaimed MS&E items
- 1.22 Privacy statement
- 1.23 Appeal process
- 1.24 Provider Claim Verification Program (PCVP)
- 1.25 Contact information
1.1 Introduction
Indigenous Services Canada (ISC)'s Non-Insured Health Benefits (NIHB) program is a national program that provides eligible registered First Nations and recognized Inuit coverage for a range of medically necessary health benefits when these benefits are not otherwise covered through private or provincial/territorial health insurance plans or social programs.
The NIHB program benefits include prescription drugs and select over-the-counter (OTC) medications, dental and vision care, medical supplies and equipment (MS&E), mental health counselling, and medical transportation to access medically required health services that are not available on the reserve or in the community of residence.
Items covered through the MS&E benefit are intended to address NIHB clients' medical needs in relation to basic activities of daily living (ADL) such as eating, bathing, dressing, toileting and transferring. MS&E benefits are covered for use at the client's place of primary residence.
The NIHB program provides coverage for cost-effective equipment and supplies that meet the client's medical needs. Cost-effective refers to the most economical equipment and supplies that are medically necessary to meet the client's essential needs. The program will request medical justification from the prescriber and/or provider, the most cost-effective equipment, for the client's specific functional needs.
Policies and guidelines are established in accordance with NIHB mandate and the mandate of the First Nations and Inuit Health Branch. NIHB benefit coverage is based on the recommendation of NIHB-recognized health professionals and is consistent with the best practices of health services delivery and evidence-based standards of care.
The guide and benefit lists contain policies related to NIHB's medical supplies and equipment benefits. Providers will be notified of changes through newsletters and bulletins, available on the Express Scripts Canada NIHB provider and client website. Clients will be notified of changes in the NIHB program update.
If you wish to enrol as an NIHB provider, refer to the provider enrolment webpage, found on the Express Scripts Canada NIHB provider and client website.
Providers and clients who do not have access to the internet can contact the NIHB Call Centre at Express Scripts Canada to request a copy of the documents mentioned above. All questions or comments regarding the MS&E Claims Submission Kit found on the Express Scripts Canada NIHB provider and client website, should also be directed to the NIHB Call Centre at Express Scripts Canada by calling their toll-free number at 1-888-511-4666.
1.2 Information for clients
Providers enrolled with NIHB are paid directly by the program so that clients do not have to pay out of pocket for eligible benefits. Should a client choose to purchase an item or pay for a service, they should confirm all of the following:
- the provider is enrolled with NIHB
- the provider will bill the program directly
- the item or service is eligible for coverage
- the provider will not charge the client any additional fees
For information on client reimbursement, please refer to section 1.17 Client reimbursement.
1.3 Client eligibility
The provider must verify that the individual is eligible for benefits under Indigenous Services Canada's NIHB program and identify any other benefit coverage available to the client, if applicable.
To be eligible, a client must be a resident of Canada, and one of the following:
- a First Nations individual who is registered according to the Indian Act (commonly referred to as a "Status Indian")
- an Inuk recognized by one of the Inuit land claim organizations as outlined in Inuit client eligibility for NIHB
- a child less than 2 years old, whose parent is an NIHB-eligible client
Refer to the Who is eligible for the NIHB program webpage or contact the NIHB regional office for more information.
More detailed information about Client Identification and Eligibility can be found in section 4 of the MS&E Claims Submission Kit, available on the Express Scripts Canada NIHB provider and client website.
1.4 Providers with MS&E specialties
- Providers dispensing specialty MS&E items must indicate the specialty items they wish to dispense on the Provider Billing Agreement form. The required qualifications to dispense such specialty items must be submitted to Express Scripts Canada as part of the enrolment process, upon request. This includes licenses, certificates, and diplomas which support the credentials required for such specialty items
- All information related to specialty items including credentials of the recognized practitioner providing the specialty items/services must be kept in the client file. This may be requested at any time, including the prior approval process
| Grouping | Specialty | Recognized practitioners |
|---|---|---|
| Audiology | Audiology services and hearing devices |
|
| Compression and burn garments | Compression garments, hypertrophic scan (burn) garments, lymphedema compression devices |
|
| Custom-made shoes and custom-made foot orthotics | Custom-made shoes and custom-made foot orthotics |
|
| Limb and body orthotics | Limb and body orthotics – Class 2 (custom-fit) and Class 3 (custom-made) |
|
| Prosthetics | Breast prostheses |
|
| Limb prostheses |
|
|
| Eye prostheses |
|
|
| Oxygen | Oxygen supplies and equipment |
|
| Respiratory supplies and equipment | Respiratory supplies and equipment |
|
| Low vision | Low vision functional assessments and training programs |
|
1.5 Terms and conditions of services
1.5.1 Advertising and promotion:
As an enrolled provider with the NIHB program, the following principles apply concerning advertising and promotion of MS&E:
- the use of names, logos, symbols, service marks and trademarks of any department or branch of the government of Canada is prohibited
- MS&E benefits are to be provided only upon request of the client. Promotional materials soliciting clients to obtain additional benefits are prohibited
- NIHB MS&E benefit coverage policies will not be used in promotional materials
- no reference should be made to NIHB coverage as "free"
1.5.2 Providers' responsibilities:
- adhere to all criteria and policies as:
- posted for NIHB providers on the Express Scripts Canada NIHB provider and client website
- listed in the Medical Supplies and Equipment Guide and Benefit Lists for First Nations and Inuit
- listed in the MS&E Claims Submission Kit, found on the Express Scripts Canada NIHB provider and client website
- written in the MS&E Billing Agreement, found in the NIHB Medical Supplies and Equipment Provider Enrolment Package on the Express Scripts Canada NIHB provider and client website
- check the Express Scripts Canada NIHB provider and client website regularly for bulletins, newsletters and alerts
- inform Express Scripts Canada immediately should any change of provider information occur by contacting the NIHB Call Centre at Express Scripts Canada
- verify client is eligible for NIHB benefits and is not already covered by a public or private benefit plan
- retain all applicable supporting documentation for benefit approval including:
- prescription or written recommendation from an NIHB-recognized prescriber/recommender
- medical assessments
- order sheets
- invoice from manufacturer
- explanation of benefits
- other documents as required by NIHB
- assess client or review assessment provided by the prescriber to dispense the most cost-effective item to meet client's medical needs
- submit prior approval forms, found on the Express Scripts Canada NIHB provider and client website, completed in full with required documentation and obtain prior approval when required before dispensing the item
- dispense items only when requested by client or caregiver
- dispense items at a maximum 3-month supply at a time
- claim reimbursement only after item(s) or service(s) have been dispensed to the client (in person or through trackable delivery) and it has been confirmed that the items have been received in complete functioning order (further instructions can be found in the MS&E Claims Submission Kit, on the Express Scripts Canada NIHB provider and client website)
- advise clients of claim status and direct clients to the Express Scripts Canada NIHB provider and client website or NIHB for First Nations and Inuit website for coverage information as needed
- maintain liability insurance which is standard with industry or regulatory bodies
- assist clients with appeal requests
- participate and cooperate in all quality assurance programs and procedures established by Express Scripts Canada or required by Indigenous Services Canada (ISC) including but not limited to:
- peer review
- providing credentials or re-credentialing processes
- complaint resolution procedures
- abide by, comply with and carry out all determinations resulting from any quality assurance program or procedure
- act in accordance with all applicable laws, and the standards of practice required by their professional regulatory authority
- provide services to all clients who are eligible under the NIHB program unless, in the provider's reasonable professional judgment, such services should not be provided. In the event this occurs, the provider shall keep a record of the circumstances of the decision not to provide services to the applicable client
- maintain records related to clients and their MS&E benefits coverage history for the period in accordance with all applicable laws, but not less than 5 years
1.6 Types of MS&E benefits
1.6.1 Open benefits
Open benefits are medical supplies and equipment that can be obtained without prior approval.
Client eligibility must be established before submitting a claim for any benefits. Providers can contact the Express Scripts Canada NIHB Call Centre at Express Scripts Canada toll-free at 1-888-511-4666 to confirm the client's eligibility. Once eligibility has been confirmed, claims may be submitted directly to Express Scripts Canada for payment. For instructions and forms to submit claims for reimbursement, refer to the NIHB Client Reimbursement webpage, found on the Express Scripts Canada NIHB provider and client website.
The following information must be kept on file:
- prescription or written recommendation from an NIHB-recognized prescriber/recommender
- manufacturer product code number, serial number, make/model of the MS&E item
- assessment or written recommendation report from a health professional, if available
1.6.2 Limited use
Limited use (LU) benefits are MS&E items that require the client to meet specific criteria for coverage. To receive benefits in this category prior approval must be obtained from the NIHB regional office.
1.6.3 Exceptions
Exceptions are MS&E items that are not currently listed in the NIHB MS&E Guide and Benefit Lists for First Nations and Inuit. Coverage may be provided on a case-by-case basis for items not listed under exclusions. Prior approval must be sought with written medical justification from the NIHB regional office.
1.6.4 Exclusions
Exclusions are MS&E items that are not listed in the NIHB MS&E Guide and Benefit Lists for First Nations and Inuit and cannot be considered for coverage or appealed. Exclusions are items that do not fall within the NIHB mandate including but not limited to:
- items used exclusively for sports, work or school
- items for cosmetic purposes
- experimental equipment and/or experimental therapy
- therapy treatment (for example, occupational therapy, physiotherapy, speech therapy, chiropractic, massage therapy, etc.)
- therapy equipment (for example, treadmills, exercise balls, etc.)
- household items/products (for example, cleaning supplies, furniture, security systems, internet, etc.)
- home renovations (for example, ramps, stair lifts, etc.)
- medical treatment (for example, surgery, insured or not)
- repair of items under warranty
- environmental controls
Examples listed under general headings are not exhaustive. If unsure of coverage please contact the NIHB regional office. More specific, exclusions may also be found under each of the benefit lists.
1.7 Prescription requirements for MS&E items
Prescriptions and written recommendations from NIHB-recognized prescribers must:
- be written for an individual client
- be written and dated on or before the service date (for example, the date the equipment or supplies are provided/dispensed)
- not be initiated or written by the service provider and supplied to the prescriber for signature
- be provided for both the initial and replacement items (unless otherwise indicated in the guide and benefit lists)
Prescriptions and written recommendations must contain all of the following information:
- client's full given names and surnames
- client's date of birth
- date the prescription was issued (day, month and year)
- prescription is valid for 12 months from the date it was issued unless otherwise indicated
- the date the prescription was faxed or sent is not the prescription date
- quantity and type of item or service being prescribed
- the prescriber/recommender's printed name and license number
- prescriber/recommender's unique hand-written or electronic signature
Note that electronic signatures without a digital certificate or evidence that the signature was applied through a secure authentication process (for example, username and password required) will be deemed invalid. Typing a name (in cursive or print) or copy-pasting a digitized picture of a hand-written signature without any digital certificate or evidence that the signature was applied through an electronic medical recording system are not considered non-reproducible signatures and are therefore not accepted.
Please refer to the appropriate section of the Medical Supplies and Equipment Guide and Benefit Lists for specific benefits that may have additional prescription requirements.
Faxed prescriptions/written recommendations must be sent directly from the health professional to the provider and require a fax header with the date sent and the sender's coordinates.
If the NIHB program discerns that a prescription/recommendation does not meet program requirements, the program can request additional information, including a new prescription/recommendation.
Prescriptions not meeting all requirements will be deemed invalid.
1.8 Prescriber/recommender requirements
Prescribers who write prescriptions and recommendations must meet the following criteria:
- be a registered member of a regulatory body
- be an approved NIHB prescriber/recommender
- be operating physically in Canada at the time the prescription/recommendation is written
1.9 Prior approval process
To ensure clients are receiving appropriate supplies and equipment that will meet their medical needs, some MS&E items require prior approval for reimbursement. Items for eligible clients requiring prior approval must only be dispensed after the approval has been granted by the NIHB regional office.
1.9.1 Steps to obtain prior approval:
To receive prior approval, the provider must:
- retrieve the benefit-specific prior approval form from the Express Scripts Canada NIHB provider and client website
- complete the entire prior approval form
- submit the completed prior approval form to the NIHB regional office; for the region in which the provider is located; with the following attachments:
- client's written prescription, recommendation or referral from a physician, nurse practitioner, or an NIHB-recognized health professional for the benefit required
- copy of any applicable third-party coverage (for example, motor vehicle insurance, workers' compensation board, private insurance, etc.)
- copy of any applicable tests and reports required as outlined in the guide and benefit lists or on the prior approval form
- any additional supporting documents that will substantiate the client's need for the benefit item.
Incomplete prior approval forms and missing supporting information can cause delays in the review process.
Additional information may be requested as necessary to adjudicate a prior approval request. No fees will be paid to complete prior approval forms or documents to support prior approval.
1.9.2 Urgent prior approval requests
Certain prior approval forms will have an indicator box marked "Urgent." Providers must check the urgent box and provide the nature of the urgency on the prior approval form only when necessary (for example, there is an urgent medical or safety need for the client to obtain an item).
1.10 Special authorization
A special authorization (SA) is a type of authorization that is client specific and allows providers to dispense and claim the approved MS&E items in accordance with the SA approval parameters and pricing policies. Once an item is approved via SA, providers may submit claims directly to Express Scripts Canada without an approval number.
Please note that the special authorization (SA) does not require an approval number when claiming reimbursement from Express Scripts Canada as this will cause adjudication errors.
1.11 Coverage of supplies, maintenance, and repairs of medical equipment covered by another benefit plan or purchased by the client
If medical equipment is funded by another benefit plan or purchased by the client, NIHB may cover associated supplies, maintenance and/or repairs when:
- the supplies, maintenance, or repairs of the medical equipment are not covered by another benefit plan
- the medical equipment is an eligible benefit of the program
- the client qualifies for the medical equipment as per the guide and benefit lists criteria and the following requirements are satisfied:
- a prescription/recommendation for the medical equipment was obtained from a program-recognized prescriber/recommender
- the medical equipment was dispensed by a provider that is recognized by the NIHB program to provide the item. This provider does not need to be enrolled in the NIHB program
- prior approval requirements and necessary information must be submitted (for example, testing/assessment information, diagnosis, device make and model, medical justification, etc.)
- additional information supporting the request is provided (for example, equipment proof of purchase)
- the coverage of supplies, maintenance, and repairs follows the policies set out in the guide and benefit lists
1.12 Recommended replacement guidelines
Recommended replacement guidelines indicate the quantity and frequency at which a benefit is eligible for coverage. Recommended replacement guidelines are based on a client's customary medical needs and the typical device's lifespan. These guidelines are listed within each benefit list.
1.12.1 Early replacement requirements
Coverage requests for any early replacement of items require prior approval and may be considered when one of the following has occurred:
- there is a substantial change in a client's medical condition (for example, substantial change in weight and/or growth, change in hearing, etc.) and the item no longer meets the client's needs
- the item is no longer functioning properly or has deteriorated during typical use
- in either of these instances, early replacement may be considered if the item is no longer under warranty and if the cost of the repair exceeds the cost of a new item
- damaged or stolen items: Coverage for the cost of damaged or stolen items may be considered on a case-by-case basis only if justification and supporting documentation are provided (for example, an incident, insurance, or medical report citing the incident)
Coverage for early replacement will not be considered for items that have been damaged as a result of misuse, or negligence.
1.13 Rentals
Rentals are used to support short-term or acute conditions. When an MS&E item is rented, the rental agreement must:
- not exceed 3 months unless otherwise indicated for specific MS&E items outlined in the benefit lists
- include the duration of the rental being requested
- indicate that rental rates are inclusive and include:
- accessories, supplies (except where indicated in the benefits lists), all equipment maintenance, delivery and pick-up, installation, education, cleaning, adjustments, replacement parts, repair and labour
- provide the monthly rental cost
- stipulate that should the purchase of the item become an option, the amount spent on the rental will be deducted from the purchase price
Please note: reimbursement for rental equipment will not exceed the total purchase price of equivalent equipment.
1.14 Repairs
Repairs may only be paid when the following criteria are met:
- the warranty on the item has expired
- the item being repaired has not already been replaced by a newer item
- it is more cost-effective than replacing the item
- they restore the item's physical condition, allowing for normal wear and tear, and include a warranty according to program requirements
- prior approval has been received
A prescription or written recommendation is not required for repairs.
Note: Repairs will not be covered if items are damaged as a result of misuse and negligence.
1.15 Warranties
As a provider, you are expected to serve as the client's advocate to request that the manufacturer or manufacturer's service depot honour the warranty on the item.
Providers must agree that during the duration of the warranty:
- repairs and services are the responsibility of the provider, manufacturer, or service designate free of charge to the program
- in situations where there are repeated technical failures, the item, device or components will be replaced by the provider at no cost to the NIHB program
1.16 MS&E claims submission and provider payment policies (effective Spring 2025)
When submitting a request for approval or a claim for payment, providers must follow the MS&E reimbursement model policies and the NIHB Price Policy. Together, these policies are known as the provider payment policies. The policies specify the:
- documentation that must be submitted when requesting for approval
- steps to determine the total dollar amount that can be claimed, known as the eligible claim amount (ECA)
There are documents available to help providers determine their ECA and understand how to submit claims. To be eligible for payment, providers must follow the NIHB program's terms and conditions outlined in their MS&E provider billing agreement, as well as:
- the MS&E Claims Submission Kit, available on the Express Scripts Canada NIHB provider and client website
- the MS&E Guide and Benefit Lists for First Nations and Inuit
- the MS&E price files, available on the Express Scripts Canada NIHB provider and client website
1.16.1 Definitions: MS&E claims submission and provider payment policies
The MS&E claims submission and provider payment policies use specific terms that are defined in the table below.
Note: Terms are listed in alphabetical order and apply to all of section 1.16 MS&E claims submission and provider payment policies.
| Term | Definition |
|---|---|
| Actual acquisition cost (AAC) | The cost paid by a provider to obtain an MS&E item from a manufacturer or wholesaler, excluding other eligible costs (OEC), as listed on a purchase invoice (the actual amount paid by a provider). The provider's AAC is not a retail price or a manufacturer's suggested retail price (MSRP). |
| Eligible claim amount (ECA) | The total dollar amount that can be submitted for approval or payment. The ECA must be calculated using the item's reimbursement model, and in consideration of the NIHB price, price type and the provider's UC price. |
| Item rationale | A documented rationale that explains why the specifically requested item is required to meet the client's need instead of other product options within the NIHB price. |
| Manufacturer's suggested retail price (MSRP) | The price that a product's manufacturer recommends it be sold for at point of retail sale on the date of service. Pricing information must be produced by the manufacturer in Canadian dollars to be deemed acceptable by the program. |
| Mark-up (MU) | The dollar amount accepted by the program as an MU, up to the program's maximum. |
| Mark-up rate (MUR) | The maximum percentage rate, established by the program used in the calculation of the eligible claim amount (ECA). MUR is only applicable to MS&E benefits with the General Reimbursement Model (GRM). |
| MS&E price file | Published document that lists the program's eligible MS&E benefits and their item code, item name, NIHB price, price type and reimbursement model. There is an MS&E price file for each region. |
| NIHB price | The dollar amount listed for an MS&E benefit in the MS&E price files. |
| Other eligible costs (OEC) | Provider costs associated with obtaining an MS&E item as listed on the purchase invoice. The program considers the following as eligible OEC's:
Other costs may be considered on a case-by-case basis, excluding taxes. MU cannot be calculated for any OEC's. |
| Price justification | A document that supports the requested price (ECA) for a specific MS&E benefit. The type of document required is different depending on the specific MS&E reimbursement model. For items with the General Reimbursement Model (GRM):
For items with the Manufacturer's Suggested Retail Price (MSRP) Reimbursement Model: MSRP supporting documentation: documentation from the manufacturer or wholesaler identifying the MS&E items requested and their corresponding MSRP price. This may be an itemized order sheet with its corresponding MSRP or another form of supporting documentation from the manufacturer or wholesaler clearly stating the pricing and item information. This is only applicable to MS&E benefits with the MSRP Reimbursement Model. For items with the NIHB Fixed Price Reimbursement Model or the Subject to Approval Reimbursement Model: An itemized cost-break down for all items, components, and services requested. |
| Purchase invoice* | The provider's invoice from a manufacturer or wholesaler for the acquisition of MS&E items, including pricing details for all items sold as part of the transaction (for example, cost of item, freight, taxes, customs). * For some MS&E benefits, a quote from the manufacturer or wholesaler to the provider that includes pricing details for all items, may be accepted. |
| Usual and customary price (UC) | The lowest price of an MS&E item that is charged by a provider to any customer of its regular business. This includes any discounts or special promotions in place on the date of service. |
1.16.2 MS&E Claims Submission Kit
The MS&E Claims Submission Kit outlines the roles, responsibilities and obligations of providers when submitting claims.
NIHB providers must read and retain a copy of the most current version of the MS&E Claims Submission Kit located on the Express Scripts Canada NIHB provider and client website. Updates to this document are announced in the MS&E newsletter. Notification of updates are posted 30 calendar days before the circulation date.
1.16.3 MS&E price files
The MS&E price files list eligible MS&E benefits. They are organized by region and are located on the Express Scripts Canada NIHB provider and client website.
The MS&E price files include the following information for each MS&E benefit:
- item name and number
- reimbursement model
- NIHB price and price type (when applicable)
Providers must use this information when calculating their eligible claim amount (ECA) to submit for approval and payment.
1.16.4 Provider payment policies
MS&E benefits are listed under generic item names without specifying makes or models. This approach allows the program to provide national coverage for a wide range of items:
- to accommodate different client needs
- to allow for product availability
- to offer a range of similar products under one benefit code
Provider payment policies are developed in consideration of these factors.
The provider payment policies include the MS&E reimbursement model policies and the NIHB Price Policy. These policies are used to determine the eligible claim amount (ECA) that can be submitted for approval or payment. These policies do not impact prior authorization requirements for program coverage criteria or client eligibility.
1.16.4.1 Steps to determine the eligible claim amount (ECA):
The following steps provide a general overview of how to determine the ECA. For specific direction, refer to the MS&E reimbursement model policies and NIHB Price Policy.
Step 1: Consult the MS&E price files, (found on the Express Scripts Canada NIHB provider and client website), to:
- identify the item or service you want to submit for approval or claim for payment
- identify the item's reimbursement model
Step 2: Determine the ECA using the item's reimbursement model.
Details can be found in section 1.16.4.2 MS&E reimbursement model policies.
Step 3: Consult the MS&E price files to compare the ECA with the NIHB price and price type (if applicable). If your calculated ECA is:
- below the NIHB price:
- proceed with submitting for approval or claiming for payment at your calculated cost
- submit a price justification and/or item rationale when requested by the program
- above the NIHB price:
- use the price type information to identify if a request exceeding the NIHB price will be considered
- determine which supporting documents must be submitted with the request
Details can be found in section 1.16.4.3 NIHB Price Policy.
1.16.4.2 MS&E reimbursement model policies
The program specifies a reimbursement model for each MS&E benefit listed in the MS&E price files, found on the Express Scripts Canada NIHB provider and client website. Each reimbursement model policy details the instructions that providers must follow to calculate their eligible claim amount (ECA).
The reimbursement models are the:
- General Reimbursement Model (GRM)
- Manufacturer's Suggested Retail Price (MSRP) Reimbursement Model
- NIHB Fixed Price Reimbursement Model
- Subject To Approval Reimbursement Model
For exception benefits, the program will inform providers of the reimbursement model used to calculate their ECA. The program will also inform providers of the required supporting documentation that must be submitted.
Note: In situations where a prior approval (PA) is requested and granted, the dollar value on the PA confirmation letter is the maximum potential amount a provider may claim for payment. Providers must follow the provider payment policies when submitting for payment.
1.16.4.2.1 General Reimbursement Model (GRM) Policy
This policy details the program's requirements that providers must follow to calculate their ECA for items with the GRM. The reimbursement model for each MS&E benefit is listed in the MS&E price files, found on the Express Scripts Canada NIHB provider and client website.
The General Reimbursement Model (GRM) bases payment on a provider's actual acquisition cost of an item, plus an NIHB specified mark-up rate. The model also considers payment for additional provider costs.
The GRM mark-up rate (MUR) is 45%. The maximum mark-up amount for each MS&E item is $4,500. The MUR is only applicable for items with the GRM.
When determining the ECA for an item with the GRM, providers must use the formula and instructions detailed below:
ECA = Actual acquisition cost (AAC) + Mark-up (MU) + Other eligible costs (OEC)
Step 1: Determine the AAC for the requested item, as noted on the purchase invoice.
Step 2: Calculate the MU, using the formula: MU = (AAC * MUR).
- MU must not exceed $4,500 per item
- MU must not be calculated for any OEC's
Step 3: Determine OEC per unit, if applicable.
Step 4: Calculate the ECA using the formula above by inputting the values from steps 1, 2 and 3.
Step 5: Compare the ECA with your UC price (including any applicable discounts or special promotions).
- if the ECA is above the UC price, then the UC price becomes the ECA
Step 6: Compare the ECA with the NIHB price and price type (if applicable). For details, refer to section 1.16.4.3 NIHB Price Policy.
Note:
- providers may submit OEC's only when listed on a purchase invoice and must submit the purchase invoice when requested by the program
- providers must submit a price justification and/or an item rationale when requested
- when a price justification and/or an item rationale are not submitted when requested, the program will determine the price and may refer the client to an alternate provider
1.16.4.2.2 The Manufacturer's Suggested Retail Price (MSRP) Reimbursement Model Policy
This policy details the program's requirements that providers must follow to calculate their ECA for items with the MSRP Reimbursement Model. The reimbursement model for each MS&E benefit is listed in the MS&E price files, found on the Express Scripts Canada NIHB provider and client website.
The MSRP Reimbursement Model bases provider payment on the manufacturer's suggested retail price. MSRPs are inclusive of mark-up and additional provider costs.
When determining the ECA for an item with an MSRP Reimbursement Model, providers must:
Step 1: Identify the item's MSRP.
Step 2: Use the item's MSRP as the ECA.
Step 3: Compare the item's ECA with your UC price (including any applicable discounts or special promotions).
- if the MSRP is above the UC price, then the UC price becomes the ECA
Note:
- additional MU or OEC must not be added to items with an MSRP Reimbursement Model
- the MSRP must not exceed amounts funded by a provincial or territorial public health benefits plan for the specific MS&E benefit
- providers must submit a price justification or an item rationale when requested by the program
- when MSRP supporting documents are not submitted when requested, the program will apply the General Reimbursement Model (GRM) to determine the ECA
1.16.4.2.3 Fixed Price Reimbursement Model Policy
This policy details the program's requirements that providers must follow to calculate their ECA for items with the Fixed Price Reimbursement Model. The reimbursement model for each MS&E benefit is listed in the MS&E price files, found on the Express Scripts Canada NIHB provider and client website.
The Fixed Price Reimbursement Model bases payment on a provider's usual and customary (UC) price, up to the NIHB price. Items under this model always have a set NIHB price that must not be exceeded.
When determining the ECA for an item with an NIHB Fixed Price Reimbursement Model, providers must:
- use their UC price (including any applicable discounts or special promotions) as the ECA, up to the NIHB price
Note:
- the ECA must not exceed the NIHB price
- providers must submit a price justification and/or item rationale when requested by the program
1.16.4.2.4 Subject to Approval Reimbursement Model Policy
This policy details the program's requirements that providers must follow to calculate their ECA for items with the Subject to Approval Reimbursement Model. The reimbursement model for each MS&E benefit is listed in the MS&E price files, found on the Express Scripts Canada NIHB provider and client website.
The Subject To Approval Reimbursement Model bases payment on a provider's usual and customary (UC) costs for all items and/or services.
When determining the ECA for an item with a Subject To Approval Reimbursement Model, providers must:
- use their UC price (including any applicable discounts or special promotions) to submit for all items and/or services requested
- submit a price justification and/or item rationale when requested by the program
1.16.4.3 NIHB Price Policy
NIHB prices are the dollar amounts listed in the MS&E price files, found on the Express Scripts Canada NIHB provider and client website. They are established by the program in consideration of the program's generic item listing at amounts that allows a wide selection of products within each generic item code. Not every MS&E benefit has an NIHB price. The published amounts are inclusive of any applicable mark-ups.
When an item has an NIHB price, it must not be claimed by default. Instead, providers are required to calculate their eligible claim amount (ECA) for submission using the item's reimbursement model. Once the ECA is calculated, it is then compared to the NIHB price and price type.
1.16.4.3.1 NIHB price types
When an NIHB price is established for an item, a price type is also assigned. The different price type specifies if an ECA above the NIHB price may be considered, and lists the documents providers must submit to support the requested price and/or item.
Each MS&E benefit with an NIHB price is categorized into one of the following price types:
- Type roman numeral 1
- Type roman numeral 2
- Type roman numeral 3
MS&E benefits without an NIHB price do not have a price type.
1.16.4.3.1.1 Type roman numeral 1
Price Type roman numeral 1 are benchmark prices set by the program at a level that allows a wide range of available product options to be claimed within the NIHB price. When submitting a request for an item within a price type, additional documentation such as a price justification and/or an item rationale are not required, unless requested by the program.
For MS&E benefits where the NIHB price is listed as Type roman numeral 1, providers must:
Step 1: Calculate the ECA using the item's reimbursement model.
Step 2: Compare the calculated ECA to the NIHB price for the requested item.
- if the ECA is below the NIHB price, providers must:
- keep the price justification and/or item rationale on file and submit it upon request
- if the ECA is above the NIHB price, providers:
- can submit a prior approval request to claim above the NIHB price for consideration
- must submit a price justification and/or an item rationale, if requested by the program
In situations where a prior approval (PA) is requested and granted, the dollar value on the PA confirmation letter is the maximum potential amount a provider may claim for payment. Providers must follow the provider payment policies when submitting for payment.
1.16.4.3.1.2 Type roman numeral 2
Price Type roman numeral 2 is a threshold price that is defined by the program which ensures the availability of a wide range of products for NIHB clients. Only in exceptional circumstances will the program consider requests where the ECA exceeds the NIHB price.
For MS&E benefits where the NIHB price is listed as Type roman numeral 2, providers must:
Step 1: Calculate the ECA using the item's reimbursement model.
Step 2: Compare the calculated ECA to the NIHB price for the requested item.
- if the ECA is below the NIHB price, providers must:
- keep the price justification and/or item rationale on file and submit it upon request
- if the ECA is above the NIHB price, providers:
- can submit a prior approval request to claim above the NIHB price for consideration
- must submit a price justification and/or an item rationale
Note: Requests to exceed a Type roman numeral 2 price are considered in exceptional circumstances only. When a request to exceed a Type roman numeral 2 price is not approved, but otherwise meets the program's eligibility and coverage criteria, it may be approved up to the NIHB price.
In situations where a prior approval (PA) is requested and granted, the dollar value on the PA confirmation letter is the maximum potential amount a provider may claim for payment. Providers must follow the provider payment policies when submitting for payment.
1.16.4.3.1.3 Type roman numeral 3
Price Type roman numeral 3 are price maximums that are set by the program. Requests to exceed a Type roman numeral 3 price will not be considered.
For MS&E benefits where the NIHB price is listed as Type roman numeral 3, providers must:
Step 1: Calculate the ECA using the item's reimbursement model.
Step 2: Compare the calculated ECA to the NIHB price for the requested item.
- if the ECA is below the NIHB price, providers must:
- keep the price justification and/or item rationale on file and submit it upon request
- if the ECA is above the NIHB price:
- request to exceed the NIHB price will not be considered
Note: When a request that meets the program's eligibility and coverage criteria, it may be approved up to the NIHB price. Providers are always required to submit a price justification and/or item rationale when requested.
In situations where a prior approval (PA) is requested and granted, the dollar value on the PA confirmation letter is the maximum potential amount a provider may claim for payment. Providers must follow the provider payment policies when submitting for payment.
1.16.4.3.2 No NIHB price
Not all MS&E benefits have an NIHB price listed in the MS&E price files, found on the Express Scripts Canada NIHB provider and client website. MS&E benefits without an NIHB price do not have a price type.
For MS&E benefits with no NIHB price, providers must:
Step 1: Calculate the ECA using the item's reimbursement model.
Step 2: Submit a price justification and/or item rationale when requested by the program.
In situations where a prior approval (PA) is requested and granted, the dollar value on the PA confirmation letter is the maximum potential amount a provider may claim for payment. Providers must follow the provider payment policies when submitting for payment.
1.17 Client reimbursement
Registered NIHB providers are reimbursed directly by the program, so clients do not have to pay for eligible benefits. Before obtaining an item or service, the client should confirm that the:
- provider is registered with the NIHB program and will bill the program directly
- provider will not charge any additional fees
- item or service is eligible for coverage by NIHB
A client who decides to pay the full cost of an item and request a reimbursement from the program should contact the NIHB Call Centre at Express Scripts Canada or their NIHB regional office before purchase to confirm eligibility of the item and the amount covered by the program.
Please note:
- to be eligible for reimbursement, the medical equipment must be eligible for coverage under the program and the client must meet program criteria for that item, as per the guide and benefit lists criteria
- prescription/recommendation must be obtained from a prescriber/recommender recognized by the program prior to purchase
- the medical equipment must be obtained by a provider that is recognized by the NIHB program to dispense the item. This provider does not need to be enrolled in the NIHB program
- reimbursement will be provided for amounts that fall within pricing as indicated in the MS&E Price Files, available on the Express Scripts Canada NIHB provider and client website
- if a client is eligible for coverage by another benefit plan, only the residual amount not covered by that plan may be submitted for reimbursement consideration
- requests for a co-payment to upgrade an item will not be accepted
- items purchased from a Canadian online store or third-party sellers using an e-commerce platform with a Canadian domain will be considered if the following conditions are met:
- the seller has a business that is registered in Canada
- the business has an address located in Canada
- the online store has a Canadian web address
- the item is paid in Canadian dollars
- unless indicated, NIHB only reimburses new items
The following documents must be submitted for reimbursement consideration:
- prescription/recommendation
- prior approval requirements including item-specific information (for example, testing/assessment information, diagnosis, device make and model, medical justification from the prescriber, etc.)
- copy of the original receipts are provided as proof of purchase, except in the case of coordination of benefits (COB), in this case, a copy is acceptable with a benefit statement from the other plan
Find additional information at NIHB Client Reimbursement.
1.18 Coupons and discounts
Eligible clients may not directly or indirectly benefit from special promotions or incentives offered by providers.
To the extent permitted by such promotions and applicable law, coupons, discounts or rebates should be applied to the NIHB claim. As a result, the eligible claim amount (ECA) is the residual amount after the application of the promotion.
1.19 Coordination of benefits
Clients who are covered by another public or private health care plan must first submit their claim to the other health care and benefits plan.
The NIHB program will:
- coordinate payment with the other payer on eligible benefits, either manually or electronically
- require a copy of the explanation of benefits form supplied by the other public or private health care plan to confirm that all other health coverage has been exhausted
- respect the prescribing requirements of the other plan or program
- continue to apply NIHB criteria for coverage
- coordinate an amount up to the full coverage of the eligible item
- require a copy of the health care plan message indicating refusal to coordinate should the other plan refuse to coordinate with NIHB
If the client no longer has alternate health coverage, the client or the provider should contact the NIHB Call Centre at Express Scripts Canada or the NIHB regional office so that the client's file can be updated.
1.20 Balance billing
Items meeting eligibility criteria will be covered in full according to NIHB MS&E reimbursement policies. Coverage is not provided to upgrade a benefit.
For an item covered by the NIHB program, providers should not:
- bill clients co-payment or extra charges
- collect a deposit
- seek compensation from a client
- condition the provision of services on payment from a client
- have any recourse against any client or person acting on behalf of the client
Certain situations may require a provider to charge a client upfront, such as a coordination of benefits claim or when an item is not covered by the NIHB program. Clients should be informed by the provider that if an item is not covered by the NIHB program, they will be responsible for paying for it without reimbursement from the program.
1.21 Unclaimed MS&E items
In cases where the client does not pick up the item, the provider should make a reasonable effort to contact the client. Attempts to contact the client should be documented in the client's file. If an approved item is not picked up after 30 days, it must be returned to the provider inventory. The provider can claim reimbursement only when the equipment or supply is dispensed to the client.
A partial reimbursement may be requested for custom-made or special-order items in situations where one of the following occurs:
- the client does not pick up the item
- the client is unable to use the item due to a worsening or improved condition
- the client passed away after the completion of the order but before the dispensing
In such cases, the custom-made item is dismantled and an invoice is submitted for the custom-made parts that cannot be reused, as well as for professional fees incurred for the creation of the item as per prior approval.
In cases, where the item is a special order:
- a claim for reimbursement is submitted for any re-stocking fees and shipping costs associated with returning the item to the manufacturer
- the item should be returned to the manufacturer/supplier if the client cannot be reached before the end of the period provided by the manufacturer/supplier's return policy
Each submission will be reviewed on a case-by-case basis. Contact the NIHB regional office to submit a claim for a restocking fee (code 99401097).
1.22 Privacy statement
The NIHB program has a responsibility to protect personal information under its control in accordance with the Privacy Act, related Treasury Board privacy policy and directives and is responsible for ensuring the personal information collected is limited to that which is necessary to administer the program.
For more information, please contact Indigenous Services Canada's Access to Information and Privacy (ATIP) Coordinator at (819) 997-8277 or aadnc.atiprequest-airprpdemande.aandc@canada. You also have the right to file a complaint with the Privacy Commissioner of Canada if you think your personal information has been handled improperly.
1.23 Appeal process
NIHB clients can appeal the denial of a benefit except for items that are outside of the program mandate and/or identified as exclusions or insured services. More information is available on the Appealing a decision under the NIHB program webpage.
1.24 Provider Claim Verification Program (PCVP)
As part of the NIHB program's risk management activities, Indigenous Services Canada has mandated its claims processor to maintain a set of pre-payment and post-payment processes, including claim verification activities.
This function incorporates the review of claims against records to confirm compliance with the terms and conditions of the NIHB program. If under any circumstances it is found that a provider has inappropriately billed the program, claim payments will be recovered; either by direct payment from the provider or withheld from future provider claim statements.
Detailed information about the Provider Claims Verification Program and procedures can be found in section 6 of the MS&E Claims Submission Kit, available on the Express Scripts Canada NIHB provider and client website.
1.25 Contact information
For information on billing contact the NIHB Call Centre at Express Scripts Canada.
Provider Phone Number (toll-free):
1-888-511-4666
Client Phone Number (toll-free):
1-888-441-4777
For more information on benefits and policies, contact the NIHB program at your applicable NIHB regional office.