4.0 Footwear equipment and supplies benefits list

4.1.1 Benefit policies

General information common to all medical supplies and equipment (MS&E) can be found in the general policies.

4.1.2 Prescriber and provider requirements

Prescriptions or recommendations for coverage must be initiated by the health professionals identified as prescribers or recommenders of the specific item as listed in the tables. Items that are prescribed by prescribers or recommenders not recognized by NIHB for the specific item will lead to denials or reversal of claims.

The following is a list of NIHB-recognized prescriber or recommender abbreviations found in this segment of the benefits list. Refer to the prescriber section of the item tables below to identify the eligible prescriber or recommender of a specific item:

• Chiropodist* — Chiropodists are recognized to prescribe custom-made foot orthotics in Ontario, Saskatchewan, and New Brunswick where their practice is regulated
• MD — Physician
• NP — Nurse Practitioner
• Podiatrist* — Podiatrists registered with provincial or territorial regulatory bodies

The following is a list of NIHB-recognized provider abbreviations found in this segment of the benefits list. Refer to the provider section of the item tables below to identify the eligible provider of a specific item:

• C.Ped — Certified Pedorthist with the title C.Ped, BOCPD registered with the Pedorthic Footcare Association (PFA) Canadian chapter
• C.Ped(C) — Canadian Certified Pedorthist
• Chiropodist* — Chiropodist registered with provincial or territorial regulatory bodies
• CO(c) — Certified Orthotist
• CPO(c) — Certified Prosthetist Orthotist
• Podiatrist* — Podiatrists registered with provincial or territorial regulatory bodies
• TOP — Technicien en orthèses et prothèses certified by the Canadian Board for the Certification of Prosthetists and Orthotists (CBCPO) or by l'Ordre des technologues professionnels du Québec (OTPQ) (Québec only)

* Chiropodists and podiatrists must include their member class, registration number, and academic designation with their signature.

4.1.3 Prior approval requirements

General prior approval requirements can be found in the general policies

To initiate the prior approval process, the Footwear Prior Approval Form, found on the Express Scripts Canada NIHB provider and client website, must be completed in full and submitted to your NIHB regional office along with the following supporting documentation:

• the prescription or recommendation or referral form signed by an NIHB-recognized prescriber for the requested benefit and dated before the service date, the date the equipment or supplies is provided
• current detailed assessment, 1 year or less from the provider, including requirements for custom-made footwear and custom-made internal footwear devices
• additional relevant information the provider, physician, podiatrist, chiropodist or nurse practitioner may have to support the request
• an explanation of benefits from any third-party coverage available to the client, for example, provincial plan, workers' compensation board, private insurance, education plan etc.

4.1.4 Exclusions

In addition to the general exclusion policy listed in the general policies, the following items are excluded from the footwear benefit and are not considered for coverage or appeal under the NIHB program:

• foot products manufactured only from 2-dimensional with extrapolation laser or optical scanning, or computerized gait and pressure analysis systems
• off-the-shelf, pre-fabricated and heat-moldable foot orthotics and internal footwear devices
• off-the-shelf footwear, for example, pair of shoes, running shoes, boots, summer sandals, etc.

4.1.5 Warranties

The manufacturer or provider warranty must include:

• no charge for necessary adjustments to custom-made foot orthotics after the final fitting, except when there has been a change in the client's medical condition that would prevent a satisfactory fit
• no charge for repairs to custom-made footwear for 1 year
• warranty covers defects due to original manufacturer workmanship and not from usual customary wear due to everyday use

4.1.6 Repairs

Repairs that are not covered under the warranty are eligible for coverage when supported by proper documentation.

The following rules apply:

• prior approval is required
• request must include detailed cost breakdown of parts, labour time and rates
• repairs must have a minimum warranty of 90 days

A description of all repairs with dates, detailed cost breakdown of parts, labour time and rates must be kept on file for each client.

Note: The NIHB program will not cover the labour cost for repairs that are covered under the warranty.

4.1.7 Replacement requirements

Recommended replacement guidelines indicate the quantity and frequency at which a benefit item will be eligible for coverage. Recommended replacement guidelines are based on a client's customary medical needs and the typical device's lifespan.

Replacement is subject to the same process as the original purchase.

All replacement requests require a new prescription except for custom-made footwear see section 4.1.7.2 Replacement of custom-made footwear.

For more general information, see section 1.12 Recommended replacement guidelines.

4.1.8 Services included in the NIHB price

The following services must be included in the NIHB price to be considered for coverage:

• initial assessment to determine the type of benefit required
• product and parts ordering and delivery from manufacturer to provider, including delivery costs and exchange rate
• shape capture or casting of the body part for the manufacturing of the device
• manufacturing of device
• dispensing of the benefit, which includes the adjustment, fitting
• no charge for the necessary adjustments after the final fitting, except when there has been a change in the client's medical condition that would prevent a satisfactory fit
• follow-up visits

4.1.9 Terminology

Included

Custom-made footwear includes custom-made foot orthotics (CMFO). Additional claims for CMFO will be denied.

4.6.1 Modifications

4.6.2 Repairs

4.6.3 Delivery