The Non-Insured Health Benefits (NIHB) Program – Information for providers of ostomy supplies

Questions and Answers

What changes are being made to ostomy supplies under the NIHB Program?

  • A national price file has been implemented for selected ostomy supplies (ostomy pouches and flanges).
  • Benefit code 99400729 for “One-piece closed-end colostomy pouch with seal” is being discontinued and replaced by two new codes.
  • Clients with permanent conditions may obtain approval for ostomy coverage for a two (2) year period (instead of the current one year period).
  • These changes are effective March 16, 2015.

Please be reminded that the NIHB Program covers claims for eligible benefits/services which are not covered by other federal, provincial, territorial or third-party health insurance plans. When an NIHB-eligible client is also covered by another public or private health care plan, claims must be submitted to the other plan first. After the first payer processes the claim and generates an Explanation of Benefits (EOB) form or equivalent document, the EOB (or equivalent) and a copy of the claim can be sent to your local Health Canada regional office for processing. The EOB or equivalent document must include the amounts paid by the first payer.

Why was the price file created?

The NIHB Program created the ostomy price file to guide the administration of requests for ostomy supplies. The price file reflects a reasonable price including a mark-up comparable to the usual and customary pricing for these items. Prices for the Northern Region have been adjusted to accommodate for higher costs.

How was this price file created?

The price file was determined by reviewing all prices paid by the NIHB Program for these select ostomy supplies in each region. This data was supplemented by manufacturers’ pricing catalogues, the price points set by other public/private health care plans, and industry group and health care professional group consultations.

Please note: The prices in the price file do not apply to those providers with pre-existing contracts with Health Canada for ostomy products.

Why were two new benefit codes created?

New benefit codes were created to enable more accurate billing of these ostomy supplies.

What are the new codes and prices for these ostomy supplies?

This information is also available on the Health Canada website at: www.healthcanada.gc.ca/nihb

How do I submit claims for clients with an existing prior approval for ostomy items which have changed codes?

For prior approvals received before March 16, 2015, providers are advised to submit their claims using the code(s) referenced in the prior approval confirmation letter.

Requests for prior approval received on/after March 16, 2015 should use the new codes and prices to avoid the prior approval request being adjusted.

On March 16, 2016, code 99400729 is discontinued. One of the two new codes must be used.

What if a client requires a specialty item or larger quantity of ostomy supplies than what the NIHB Program covers?

For clients who require more ostomy supplies than are regularly covered by the Program, or those who require a specialty item, the prior approval request must be supported by a prescription stating the medical need/justification.

How do I request coverage for two (2) years of ostomy supplies when a client has a permanent condition?

Prior approval requests for ostomy supplies must indicate whether the client has a permanent or temporary need for ostomy supplies.

If a client has a permanent condition that requires coverage of ostomy supplies listed on the price file, approval for coverage may be extended for these items for a two (2) year period. During this period, you will not need to contact your local Health Canada Regional Office again to obtain approval for dispenses of these ostomy supplies. Please bill Express Scripts Canada as per directions on the confirmation letter.

NIHB’s frequency limit for ostomy products remains the same. Please note, items that have an annual frequency limit must be provided and billed for no more than a three-month period at a time. This applies to items with or without prior approval.

Clients who indicate that they have a temporary condition will continue to require a yearly prescription.

Where can I find information on ostomy supplies covered by the NIHB Program?

The Medical Supplies and Equipment (MS&E) Benefit List provides a description of the ostomy supplies covered by the NIHB Program, along with information pertaining to benefit codes, requirements for prior approval, and applicable frequency limitations. Information on the MS&E benefit is available on the Health Canada website at: Health Canada website at: http://www.hc-sc.gc.ca/fniah-spnia/nihb-ssna/benefit-prestation/medequip/index-eng.php

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