Guide for Medical Supplies and Equipment Benefits: Non-Insured Health Benefits

September 2017

This guide provides information on the Health Canada Non-Insured Health Benefits (NIHB) Program’s policies that are relevant to medical supplies and equipment (MS&E) providers. It explains the extent and limitations of the NIHB Program’s MS&E benefits by describing the important elements of each associated policy. It also lists website addresses to give providers quick access to related forms and more detailed Program information.

Refer to the Medical Supplies and Equipment Claims Submission Kit available at Express Scripts Canada, for the process to submit claims for payment of goods and services rendered to eligible clients.

Table of Contents

1. Introduction

Health Canada’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.

NIHB Program benefits include a range of prescription drugs and over-the-counter (OTC) medications, dental and vision care, medical supplies and equipment, mental health counselling, and transportation to access medically required health services that are not available on 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). ADL’s refer to the basic tasks of everyday life such as eating, bathing, dressing, toileting, and transferring.

The Guide for Medical Supplies and Equipment (MS&E) Benefits explains the benefits available by the NIHB Program and the policies under which the Program will reimburse MS&E items provided to eligible clients.

In addition to the Guide, Express Scripts Canada’s NIHB MS&E Claims Submission Kit sets out the terms and conditions for the submission of claims under the MS&E Provider Agreement.

As policies and procedures evolve, the Guide is updated accordingly and providers are advised of these changes through the Program’s newsletters distributed by Express Scripts Canada.

Providers are advised to read and retain the most current version of the Guide as well as Newsletters to ensure continued compliance with their Express Scripts Canada Provider Agreement for the NIHB Program. In the event of contradiction between versions of the Guide, the provisions of the Health Canada web-posted information will prevail.

2. Medical Supplies and Equipment General Policies

MS&E benefits are covered in accordance with the mandate of the NIHB Program. Coverage for specific MS&E benefits is based on policies and guidelines established by Health Canada. These decisions are based on the judgement of recognized health professionals consistent with the best practices of health services delivery and evidence-based standards of care. This applies to open benefits (items that do not require a prior approval) on the NIHB Program’s MS&E benefit list as well as items that require prior approval.

NIHB will cover the cost of items that meet Program coverage criteria. As such, providers must not charge NIHB clients a co‑payment or extra bill for any item the Program is extending coverage.

Please note that the majority of MS&E items require prior approval for reimbursement. In order to avoid delays and ensure claims are reimbursed, items requiring prior approval should only be dispensed after the approval is granted by the appropriate Health Canada regional office. Section 2.3: Prior Approval Requirements for additional details.

2.1. Exceptions

Exceptions are items that are not listed on the MS&E Benefit List. NIHB may provide coverage on a case-by-case basis as long as the item is not an exclusion of the Program. A request for an exception requires a written medical justification and a completed prior approval request form. MS&E providers should refer to section 2.4 of this guide and follow the same prior approval requirements to request coverage for exception items.

2.2. Exclusions

Exclusions are items that are not listed on the MS&E Benefit List and cannot be considered for coverage or appealed under the NIHB Program. General exclusions include:

  • items used exclusively for sports, work or school;
  • items for cosmetic purposes;
  • experimental equipment and/or experimental therapy;
  • therapy treatment (e.g. Occupational Therapy, Physiotherapy, Speech Therapy, Chiropractic and Massage Therapy)
  • therapy equipment (e.g. treadmills, exercise balls);
  • household items/products; and
  • home renovations (e.g. ramps, stair lifts).

Specific exclusions are also listed under each MS&E sub-benefit area.

2.3. Prescription Requirements for MS&E Items

Prescriptions (Rx) submitted to NIHB Regional Offices and kept on file by providers must contain the following information:

  • prescription date, signed within the past 12 months  (a fax date is not accepted as the prescription date);
  • prescribers’ hand-written signature (a stamped or electronic prescriber signature is not accepted, unless the provider has obtained permission from the regional office to use this format);
  • client’s full given name and surname; and
  • item or service being prescribed.

Please note that the Program will only accept a prescription that is written for a specific client.

For certain items, the NIHB Program will accept a recommendation from an NIHB-recognized health professional. The recommendation should include the same information as a prescription.

Where the prescription is in the form of a referral to another health professional, it must include the specific type of assessment required. For example:

Prescription from a physician or nurse practitioner addressed to an occupational therapist (OT) requesting an assessment and recommendations for a wheelchair.

Regardless of the form used, all information indicated above should be provided.

Faxed prescriptions require a fax header with the date sent and the sender’s coordinates. 

2.4. Prior Approval Requirements

To request a prior approval, the MS&E provider completes the following steps:

  • obtains client’s written prescription, recommendation or referral from a physician, nurse practitioner, or an NIHB-recognized health professional (further details provided in the sub-benefit sections of this guide);
  • confirms client’s identification information (refer to section 5.0 B – Client Eligibility);
  • obtains a copy of any third-party coverage (e.g. workers’ compensation board, private insurance etc.);
  • indicates the date of service (if one-time item), or service period (for multiple dispenses); and
  • submits the above information along with the prior approval form to the Health Canada regional office (consult section 3.0 for the prior approval forms as well as the list of additional supporting documents that may be required when submitting requests).

Note: Prior approval requests for First Nation residing in British Columbia who are eligible under the First Nations Health Authority (FNHA) should be submitted to:

First Nations Health Authority (FNHA)
757 West Hastings Street, Suite 540
Vancouver, British Columbia
V6C 3E6

Toll-free: 1-800-317-7878
Fax: 1-888-299-9222

For NIHB clients residing in British Columbia, who are not eligible under the FNHA, please contact the Health Canada Alberta Regional Office for assistance (see coordinates in the Appendices of this guide).

The NIHB Program reserves the right to request additional information if deemed necessary to adjudicate prior approval requests.

2.5. Recommended Replacement Guidelines

The NIHB Program’s recommended replacement or frequency guidelines are based on the usual and customary medical needs of clients. For individual items, refer to the recommended replacement guidelines in the MS&E Benefit List. Requests exceeding these guidelines may be considered on a case-by-case basis when supported by clinical rationale from a recognized health professional.

Items that have a quantity limit are not to exceed a three-month supply at a time. This applies to items with or without prior approval.

Early replacement of equipment and devices will only be considered if a substantial unanticipated change has taken place in a client’s medical condition (e.g. substantial change in weight and/or growth), or if the equipment or device has deteriorated during the course of a normal use and cannot be repaired in a cost effective manner. When requesting coverage for an early replacement, information documenting the change in the client’s medical needs is provided at the time of the request.

Note: Coverage for early replacements will not be provided if items are damaged as a result of misuse, carelessness or negligence.

2.6. Coupons and Promotions

When accessing benefits through the NIHB Program, eligible clients may not directly or indirectly benefit from special promotions or incentives offered by providers. This includes but is not limited to: coupons, discounts, points programs or rebates in the form of cash and/or goods. 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 amount claimed through the NIHB Program is the residual amount after application of the promotion.

2.7. Rentals

When an MS&E item is rented, the rental agreement can be for a period of up to three months and is not to exceed the cost of purchasing the item. The rental agreement must include equipment maintenance and repair as the NIHB Program does not cover these costs. The rental agreement must also include a clause stipulating that should the purchase of the item become an option, the amount spent on the rental will be deducted from the purchase price.

2.8. Repairs

Under the NIHB Program, only the most recently purchased item qualifies for the coverage of maintenance and repairs. Repairs are to restore the item’s physical condition, allowing for normal wear and tear, and include a warranty according to industry standards.

Please note that repairs are eligible for coverage only when the warranty has expired. A prior approval is required for all repairs and, if more cost effective, the item should be replaced instead of repaired. A prescription is not required for repairs.

Note: Repairs will not be covered if items are damaged as a result of misuse, carelessness, or negligence

2.9. Warranties

For MS&E items with warranty coverage, as a minimum, the warranty coverage must specify 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; and
  • 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.

MS&E providers 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.

3. Benefit Description and Conditions

Medical Supplies and Equipment Benefit List

The NIHB Program maintains an up-to-date list of MS&E items that are eligible benefits. Items on the MS&E Benefit List are covered for use in a home or ambulatory care setting.

The MS&E Benefit List is organized in seven sub-benefit areas:

  • general MS&E;
  • audiology;
  • orthotics and custom footwear;
  • oxygen equipment and supplies;
  • pressure garments and pressure orthotics;
  • prosthetics; and
  • respiratory equipment and supplies.

Providers can consult the MS&E Benefit Lists to confirm whether items are covered by the Program.

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3.1. General Medical Supply and Equipment Benefits

3.1.1. General Medical Supply and Equipment Benefit Categories

The general MS&E benefit categories are:

  • bathing and toileting aids;
  • catheter supplies and equipment;
  • dressing aids;
  • feeding aids;
  • incontinence supplies and equipment, such as diapers, and liners;
  • lifting and transfer aids;
  • low vision aids;
  • miscellaneous supplies and equipment;
  • mobility aids, such as walking aids, walking aids accessories, wheelchairs, wheelchair cushions and wheelchair parts;
  • ostomy supplies and devices; and
  • wound dressing supplies, such as adhesive tapes, dressing strips and bandages.

3.1.2. Prescriber/Provider Requirements

General MS&E benefits must be prescribed by a physician, nurse practitioner, or an NIHB-recognized health professional. Items should be dispensed by providers that are enrolled with the Program (through the Medical Supplies and Equipment Provider Agreement accessible at Express Scripts Canada provider web site).

3.1.3. Prior Approval Process

For a list of general MS&E items that require prior approval, please refer to the MS&E Benefit List.

To initiate the prior approval process, the NIHB General MS&E Prior Approval Form along with the following supporting documentation are required by the regional office:

  • the prescription or referral form signed by a physician, nurse practitioner, or NIHB-recognized health professional and any other information the provider/prescriber may have to support the request;
  • for low vision aids, the NIHB Program accepts prescription from Optometrists, as well as from Certified Ophthalmic Technicians/Medical Technologists (OMT) working under the Stanton Territorial Health Authority (STHA) in Northwest Territories and Nunavut; and
  • any additional information required as listed in section 3.1.4 of this guide.

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3.1.4. General MS&E Benefit Policies

A. Criteria and Required Information

Requests for specific MS&E items are adjudicated according to the following criteria:

a) Breast pumps:

Breast pumps are considered for coverage when a mother presents medico-physical complications hindering the normal physiological process of breast feeding. Medical documentation of the mother’s condition is required to support the request.

b) Catheter supplies and equipment requiring prior approval:

Information concerning the client’s diagnosis, a justification for the use, the type and the quantity of catheter supplies and equipment are required as part of the request for coverage. Recommended replacement guidelines are available in the MS&E Benefit List. Requests exceeding the frequency guidelines require a medical justification.

c) Dressings requiring prior approval:

The client’s diagnosis and a wound/ulcer assessment from a nurse or physician are required as part of the request for coverage. The assessment should include the following information:

  • wound site and size (indicate in mm or cm);
  • tunneling (direction & depth);
  • wound bed;
  • wound border;
  • peri-wound skin condition;
  • exudate amount;
  • exudate type;
  • wound odour;
  • wound care treatment with type/size of dressings being used;
  • frequency of dressing changes; and
  • anticipated healing time.

d) Feeding pump

Medical documentation that establishes the client’s inability to receive feeding through gravity is required to request coverage.

e) Incontinence supplies

i) Disposable diapers and pull-up briefs

NIHB may provide coverage for up to 450 incontinence items, which can be either one type of product or a combination of different products, over the course of a three month period. The following information is required when requesting coverage:

  • medical diagnosis of the cause(s) for the incontinence;
  • type of incontinence (urine/stools or both);
  • when the incontinence occurs (day/night or both);
  • type of incontinence supplies needed;
  • size of the incontinence supplies requested (does not apply to children’s sizes or liners);
  • quantity of incontinence supplies needed; and
  • any other supporting information (e.g. temporary or permanent condition).

Note: A medical justification is required for quantities in excess of 450 incontinence items per three month period.

ii) Pant (brief) mesh, washables

NIHB provides coverage for a maximum of three per month.

iii) Disposable Underpads

NIHB provides coverage for a maximum of 50 disposable underpads per month for regular bowel care routine.

iv) Reusable Underpads

NIHB provides coverage for a maximum of two reusable underpads to protect the mattress during the first year of the request, and one mattress underpad per subsequent year.

Refer to the MS&E Benefit List section 2.6.2 for the incontinence supplies price file.

f) Lift, hydraulic (powered):

Request for coverage must include an Occupational Therapist (OT)/Physiotherapist (PT) report summarizing the client’s:

  • medical, physical status and functional level (e.g. mobility);  
  • transfer status; and
  • justification as to why a standard hydraulic lift will not meet the client’s need.

g) Manual wheelchairs:

NIHB covers one wheelchair every five years. An OT/PT report explaining how the wheelchair will meet the client’s functional needs is required. The report should include the client’s:

  • medical, physical, and functional status, including the client’s mobility;
  • transfer status; and
  • height and weight.

Note: clients with an above-the-knee or below-the-knee amputation automatically qualify for coverage of a manual wheelchair.   

h) Power wheelchairs:

NIHB covers one wheelchair every five years for use in a home or in another ambulatory care setting.

The provider must submit an OT/PT report explaining how the wheelchair will meet the client’s functional needs. The report should include the client’s:

  • medical, physical, and functional status, including the client’s mobility (include information regarding how the wheelchair will be used to complete basic activities of daily living (ADL) such as eating, bathing, dressing, and toileting);
  • transfer status; and
  • height and weight.
B. Exclusions

The general exclusion policy (section 2.2) continues to apply. The following items are excluded from the general MS&E benefit and are not considered for coverage or appeal under the NIHB Program:

  • environmental protection devices and supplies (e.g., masks, air cleaners, filters, UV protection garments and lotions, etc.);
  • permanently fixed equipment;
  • lift chairs;
  • scooters; and
  • topical or hyperbaric oxygen treatment.
C. Services included in price

The following services are to be included in the price of the requested MS&E items:

  • initial assessment to determine the type of item required;
  • manufacturing of device;
  • dispensing of the item, which includes the adjustment, fitting; and
  • follow-up visit(s).

3.1.5. General Medical Supply and Equipment Benefit Grid

3.2. Audiology Benefits

3.2.1. Audiology Benefit Categories

The audiology benefit categories are:

  • hearing aid, bone conduction, conventional analog;
  • hearing aid, CROS/BiCROS;
  • hearing aid, programmable analog;
  • hearing aid, digital entry level; and
  • hearing aid services, fees, repairs and supplies.

3.2.2. Prescriber/Provider Requirements

Audiometric tests must be prescribed by a physician, nurse practitioner, or audiologist and be performed by an audiologist, audio-prosthetist, hearing instrument practitioner, or other NIHB-recognized audiology provider. Audiology equipment and supplies may be prescribed by a physician, nurse practitioner, or audiologist.

In addition,  the NIHB Program will accept recommendations from hearing instrument practitioners (HIP) for audiometric tests and hearing equipment and supplies for adults 18 years of age or older. This applies only in provinces and territories where the practice of HIP is regulated, and where this activity is within their scope of practice and where items and services can be provided independently and in accordance with all appropriate acts and regulations that oversee the delivery of hearing services.

Audiology equipment and supplies may be provided by an audiologist or a hearing aid dispenser that  is enrolled with NIHB.

Batteries may be provided by an NIHB enrolled MS&E provider, including audiologist, hearing aid specialist, other medical supply and equipment provider, and pharmacies.

3.2.3. Prior Approval Process

All audiology benefits require prior approval, including testing and new/replacement hearing aids. The only exceptions are for batteries and accessories which do not require a prior approval.

To initiate the prior approval process, the NIHB Hearing Aid and Hearing Aid Repair Prior Approval Form along with the following supporting documentation are required by the regional office:

  • prescription or referral form signed by a physician, nurse practitioner, or audiologist for the audiometric test and hearing aid equipment and supplies;
  • results of most recent audiometric test (six months or less);
  • other related information the provider, physician, nurse practitioner, or audiologist may have to support the request; and
  • details of the hearing aid device as described in section 3.2.4 of this guide (Audiology Benefit Policy).

In the case of a replacement aid, the following is required:

  • the current hearing aid information (e.g. model number, extra features)

In the case of repairs, the following information is required:

  • manufacturer name;
  • model number or name;
  • date fitted; and
  • serial number.

Once the provider has dispensed the hearing aid, the provider completes the following steps:

  • signs section 7 of the NIHB Hearing Aid and Hearing Aid Repair Prior Approval Form;
  • includes a reference to the original PA number;
  • attaches a copy of the manufacturer’s invoice; and
  • submits the form and supporting documents to the Health Canada regional office for processing.

By signing the NIHB Hearing Aid and Hearing Air Repair Prior Approval Form, the provider attests that the client has received the device and is satisfied with the equipment, repair, and instructions provided.

Providers are to retain a copy of the submitted forms and documentation for audit purposes.

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A. Medical Guidelines and Required Information

To request hearing aids and/or replacement of hearing aids, the following documentation and information are required:

  • a recent audiogram (less than six months old);
  • the manufacturer’s name;
  • the model and size of the requested aid; and
  • information on any previous NIHB coverage and/or repairs for audiology items.
B. Exclusions

Please note that the general exclusion policy (section 2.2) continues to apply. The following items are excluded from the audiology benefit and are not considered for coverage or appeal under the NIHB Program:

  • items used exclusively for education/school;
  • surgical implants;
  • hearing protectors used in work-related situations; and
  • therapy treatment, such as speech therapy.
C. Warranties

All hearing instruments and/or devices must carry, at a minimum, a two-year warranty on repairs and a one-year ‘loss and damage replacement’ coverage for one occurrence per aid. Warranties that go beyond these provisions must extend the same benefits to NIHB clients. All items must have a 90-day return privilege at no cost to the hearing aid provider.

D. Follow-up

After the client has had an opportunity to try their device(s) for a maximum of ninety (90) days, further evaluation and follow-ups may be required. If requested by the client, the following services are to be provided:  

  • appropriate reinforcement of information, instructions, and retraining on the device, if necessary*;
  • any modifications to improve the comfort of the device;
  • any modifications to the electroacoustic characteristics of the device based upon reactions and experiences of the client;
  • any adjustments or changes to amplification levels due to client reactions to enhance client benefit from the device; and
  • other further adjustments.

*Note: should the client experience any difficulty with the hearing aid usage and/or tolerance, the provider is to identify the cause of the problem and resolve the issue.

Follow-up after warranty has expired

After-care services are services that take place when the dispensing fee services under the manufacturer’s warranty have expired (minimum of two years), or when services are not covered by the manufacturer’s warranty.

Most after-care services will involve:

  • adjustments to the client’s fitting, including earmold repairs or replacements which may be necessary from time to time, undertaken as part of the general after-care services. These adjustments may be invoiced according to the fee schedule; and
  • advice to the client outside a formal appointment, regarding their fitting or their hearing loss which is accommodated by the clinic and/or service provider.
E. Repairs

Repairs are to restore the hearing aid to its original level of performance. While a prescription is not needed for repairs, prior approval is required for all billable hearing aid repairs.

Out-of-office and in-office hearing aid repairs are not subject to service fees while the item is under warranty by the manufacturer, unless the out-of-office repair results in a charge not covered by the warranty.

Out-of-office hearing aid repairs that incur a charge by the manufacturer (after the original manufacturer’s warranty has expired), should include a warranty period on the repair. A replacement should be considered when more economical than a repair.

Warranty on Repairs

Repair warranty periods must be consistent with the current Canadian Auditory Equipment Association-NIHB agreement:

  • repairs carried out on a hearing aid during the product purchase warranty period are guaranteed for a maximum of 12 months after repair or until the original product warranty expires, whichever comes first;
  • all repairs and remakes carried out on a hearing aid after the warranty period expires will be subject to a maximum cost outlined in the pricing grid and will carry a 12-month warranty if the hearing device is less than five years old;
  • charges for repairs and remakes can only be billed after the warranty period, 24 months for new aids and 12 months after the repair or remake of an aid; and
  • a remake includes the provision of a new shell for the aid and replacement of required existing electronic components to ensure that the aid has been returned to the equivalent operating standard of a new aid.
Repair Timeline

If same-day repairs cannot be completed, a loaner hearing aid should be provided free of charge if requested by the client. A Behind The Ear (BTE)-type hearing aid is acceptable as a loan hearing aid for In The Ear (ITE) and In The Canal (ITC) hearing aids. If the hearing aid is not repaired at the point of service and needs to be sent to another location to be repaired, the device should be returned to the client promptly. Batteries and repair services must be available at the point of service during regular business hours. The provider should have at least one permanent business location with the capacity to repair devices.

3.2.5. Audiology Benefit Grid

3.3. Orthotics and Custom Footwear Benefits

3.3.1. Orthotics and Custom Footwear Benefit Categories

The orthotics and custom-made footwear benefit categories are:

Orthotics (excluding custom-made foot orthotics):

  • head, torso and/or spine orthoses;
  • limb orthoses for lower and/or upper extremities; and
  • orthotic supplies.

Custom-made Footwear:

  • custom-made foot orthotics;
  • custom-made shoes; and
  • modifications to stock footwear.

3.3.2. Prescriber/Provider Requirements

Orthotics

Limb and body orthotic devices must be prescribed by:

  • Class I (soft): physician or nurse practitioner
  • Class II (rigid) and Class III (custom-made): physician

Limb and body orthotic devices must be provided by:

  • Class I (soft): certified orthotist (CO(c)), certified prosthetist orthotist (CPO(c)), technicien en orthèses et prothèses (TOP) certified by the Canadian Board for the Certification of Prosthetists and Orthotists (CBCPO), TOP certified by l’Ordre des technologues professionnels du Québec (OTPQ) (Quebec only), or NIHB-recognized MS&E provider
  • Class II (rigid) and Class III (custom-made): CO(c), CPO(c), TOP certified by the CBCPO, or TOP certified by the OTPQ (Quebec only)

Note:  Foam cervical collars, abdominal supports, hernia trusses and sacral or lumbosacral supports, and cloth or elastic braces with or without rigid stays, can be provided by any NIHB recognized MS&E provider.

Custom-made Footwear

Custom-made shoes and modifications to stock footwear must be prescribed by a:

  • physician;
  • nurse practitioner; or
  • podiatrist (Doctor of Podiatric Medicine (D.P.M) only).

Custom-made foot orthotics must be prescribed by a:

  • physician;
  • nurse practitioner; or
  • podiatrist (D.P.M only);.

Custom-made shoes, custom-made foot orthotics and modifications to stock footwear must be provided by a (according to their provincial/territorial scope of practice):

  • CO(c);
  • CPO(c);
  • TOP certified by OTPQ (Quebec only) or the CBCPO;
  • chiropodist (DPodM) registered with provincial / territorial regulatory bodies;
  • podiatrist (D.P.M. only) registered with provincial or territorial regulatory bodies; or
  • Canadian-certified pedorthist (C.Ped(C)).

3.3.3. Prior Approval Process

Prior approval is required for all orthotic devices, custom-made foot orthotics, custom-made shoes, or modifications to stock footwear.

To initiate the prior approval process, the NIHB Orthotics-Custom Shoes-Prosthetics-Pressure Garments Prior Approval Form along with the following supporting documentation are required by the regional office:

  • the prescription (if required as per the replacement process for orthotics in 3.3.4) or referral form signed by the appropriate health professional;
  • detailed assessment from the provider, including requirements for custom-made shoes and custom-made internal footwear devices as specified in section 3.3.5 of this guide;
  • any other information the provider, physician, nurse practitioner, or podiatrist (D.P.M) may have to support the request;
  • a copy of an Explanation of Benefits (EOB) form from any third-party coverage available to the client (e.g., workers’ compensation board, private insurance, etc.); and
  • additional required information described in section 3.3.5.of this guide.

3.3.4. Replacement Process for Orthotics

The original prescription* may be used for a replacement request when the:

  • orthotic was initially covered by the NIHB Program (except for custom-made shoes or orthotics);
  • item addresses a permanent medical condition; and
  • replacement is within the frequency guideline.

A new prescription* is required for a replacement when the:

  • items are custom-made shoes or custom-made foot orthotics;
  • item addresses a temporary condition (defined as a condition that lasts less than 12 months);
  • client changes providers;
  • client’s medical condition changes; or
  • request is for an early replacement.

*Note: A copy of the prescription and prescriber number must be kept in the client’s file at the provider’s office with all orthotic replacements

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3.3.5. Orthotics and Custom Made Footwear Benefit Policies

A. Criteria and Required Information

In addition to the supporting documents described in section 3.3.3, the following are the criteria for coverage and information required to authorize the orthotics and custom made footwear benefits:

a) Custom thoracolumbarsacral sacral orthoses

Orthotics for spinal fractures often need to be fitted while the client is in an acute care setting. The following information is required for coverage:

  • the diagnosis;
  • date of fracture; and
  • the date of surgery, if applicable.

b) Custom-made shoes

The following information is required for coverage:

  • measurements of the feet;
  • photographs of the feet (preferred) and/or templates/drawing/tracing of the contour of the feet;
  • prescriber type (i.e. physician, nurse practitioner, or podiatrist (D.P.M only));
  • the provider’s qualification(s);
  • the client’s diagnosis and biomechanical/medical assessment (e.g. significant deformities of the feet);
  • an explanation as to why the client’s needs cannot be met by off-the-shelf orthopaedic footwear;
  • the casting technique (e.g. plaster of Paris slipper cast);
  • manufacturing technique, material used, and design of shoes;
  • name of the laboratory; and
  • warranty details.

c) Custom-made Foot Orthotics

The following information is required for coverage:

  • diagnosis and client’s symptoms (e.g. heel pain, metatarsalgia, or tendinitis);
  • biomechanical/medical assessment (e.g. pronation, pes planus/flat feet, bunions, or claw toes);
  • type of device (e.g. accommodative or functional);
  • casting technique:
    • NIHB-accepted casting techniques are: plaster of Paris slipper cast; foam box; contact digitizing (Amfit); STS slipper casting, and full-3D optical scanning (e.g. Cast CAD);
  • manufacturing technique and material used;
  • name of the laboratory; and,
  • warranty details.
B. Exclusions

The general exclusion policy (section 2.2) continues to apply. The following items are excluded from the orthotics and custom-made foot orthotics benefits and are not considered for coverage or appeal under the NIHB Program:

  • foot products manufactured only from 2D with extrapolation laser or optical scanning, or computerized gait and pressure analysis systems;
  • pre-fabricated foot orthotics and internal footwear devices;
  • off-the-shelf and orthopaedic/therapeutic footwear (e.g. pair of shoes, running shoes, boots, summer sandals, etc.); and
  • therapy treatment and/or therapy equipment, such as, but not limited to:
    • electrospinal orthosis;
    • neurostimulators;
    • direct passive movement devices; and
    • electromagnetic stimulators for osseous growth.
C. Services included in price

The following services are to be included in the price of the item:

  • initial assessment to determine the type of benefit required;
  • casting of the body part for the manufacturing of the device;
  • manufacturing of device;
  • dispensing of the benefit, which includes the adjustment, fitting; and
  • follow-up visit(s).
D. Warranty

The manufacturer/provider warranty must include:

  • no charge for necessary adjustments to custom-made foot orthotics for a period of three months after the final fitting, except when there has been a change in the client’s medical condition that would prevent a satisfactory fit;
  • breakage guarantee for six months and no charge for necessary adjustments to a custom-made orthoses (limb and body) for a period of three months after the final fitting except when there has been a change in the client’s medical condition that would prevent a satisfactory fit;
  • breakage guarantee for two months and no charge for necessary adjustments to a customized orthoses/pre-fabricated (limb and body) for a period of 30 days after the final fitting except when there has been a change in the client’s medical condition which would prevent a satisfactory fit; and
  • no charge for repairs to custom-made shoes for a one year period.
3.3.6. Orthotics and Custom Footwear Benefit Grid

3.4. Oxygen Equipment and Supplies Benefits

3.4.1. Oxygen Equipment and Supplies Benefit Categories

The oxygen equipment and supplies benefit categories are divided into:

  • oxygen systems and equipment; and
  • oxygen supplies.

3.4.2. Prescriber/Provider Requirements

For NIHB Program coverage, home oxygen equipment and supplies are to be prescribed by a physician or nurse practitioner and provided by an oxygen provider enrolled with NIHB with appropriate health care staff including regulatory affiliations (i.e. registered respiratory therapist/registered nurse/licensed practical nurse/registered practical nurse (Ontario) familiar with respiratory conditions).

3.4.3. Prior Approval Process

Prior approval is required for all home oxygen equipment and supplies benefits.

To initiate the prior approval process, the NIHB Home Oxygen and Respiratory Equipment and Supplies Benefits Approval Form along with the following information are required by the regional office:

  • prescription detailing the oxygen flow (litres per minute) and numbers of hours per day;
  • specify whether the request is for a new application or a renewal for home oxygen;
  • expected dates of service (e.g. May 01, 2015 to July 31, 2015);
  • any other information the provider/physician or nurse practitioner may have to support the request;
  • a copy of an Explanation of Benefits (EOB) form from any third-party coverage available to the client (e.g., workers’ compensation board, private insurance, etc.); and
  • required information described in section 3.4.4 of this guide.

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3.4.4. Oxygen Equipment and Supplies Benefit Policies

The following criteria are requirements to authorize oxygen equipment and supplies benefits:

A. Criteria and Required Information

a) Concentrator/portable concentrator/portable oxygen/homefill, initial request (three month approval only)

Home oxygen may be considered for coverage by the NIHB Program once the client’s condition is stabilized and treatment regimen is optimized.

Note: The arterial blood gas (ABG) results obtained during an acute exacerbation are not accepted.

If ABG is not available, refer to section D.

Qualifying medical indications for home oxygen include:

  1. a resting PaO2 on room air of 55 mmHg or less (ABG is needed);
  2. a resting PaO2 on room air between 56 and 59 mmHg with evidence of cor pulmonale, pulmonary hypertension and/or secondary polycythemia (ABG and supporting documented evidence provided by a physician is needed);
  3. persistent PaO2 between 56 and 59 mmHg with exercise limitation due to hypoxemia with significantly greater exercise capability and/or significantly decreased shortness of breath on oxygen compared to room air (ABG and a resting and walking oximetry is needed);
  4. nocturnal hypoxemia when nocturnal oxygen desaturation is less than 88% for 30% of the night and sleep disordered breathing is ruled out (ABG and a nocturnal oximetry is needed);
  5. New York Heart Association Stage IV Heart Disease (ABG and supporting documented evidence provided by a cardiologist is needed);
  6. palliative care (less than three (3) months life expectancy) for clients demonstrating persistent hypoxemia:
    • PaO2 on room air of 60 mmHg or less or O2 saturation of 92% or less (a resting oximetry is needed) dyspnea that cannot be improved with medication and/or comfort analgesia (ABG or a resting oximetry is needed) along with a clear diagnosis supporting the end stage of palliative condition by a physician, nurse practitioner or palliative care team member (i.e. Registered Nurse) to document noting that the dyspnea cannot be improved with medication and/or noting that comfort analgesia are needed.

b) Concentrator/portable concentrator/portable oxygen/homefill renewal (after three months and again after 12 months from the initial starting date)

The client must meet one of the following:

  1. a resting PAO2 on room air of 55 mmHg or less (ABG is needed);
  2. a resting PaO2 on room air between 56 and 59 mmHg, when there is evidence of cor pulmonale, pulmonary hypertension and/or secondary polycythemia;
  3. persistent PaO2 between 56 and 59 mmHg, when there is evidence of desaturation on exertion (ABG and a resting and walking oximetry is needed);
  4. persistent PaO2 between 56 and 59 mmHg, when there is evidence of nocturnal oxygen desaturation (ABG and nocturnal oximetry is needed); or
  5. New York Heart Association Stage IV Heart Disease (resting oximetry is needed).

The NIHB Program covers up to three months of palliative oxygen. Following this three month period, a client will be considered a regular recipient of oxygen coverage therefore an ABG will be requested.  

An ABG on room air or an oximetry test is required yearly from the initial starting date of home oxygen for medical indications 1 and 2, and based on the client’s condition.

c) Portable oxygen cylinders/liquid initial and renewal and oxygen for medical travelling

Providers are required to give the Regional Office the same medical information described in a) and b) above.

When applicable, NIHB covers oxygen portability for a maximum of eight hours per day away from the primary residence. Coverage is authorized for the primary residence only, with the exception of additional oxygen requirements due to travel for the purpose of attending a medical appointment. While supplemental oxygen for the purpose of attending medical appointments is assessed on a case-by-case basis, it is expected that the client will use the oxygen concentrator when possible.

B. Exclusions

The general exclusion policy (section 2.2) continues to apply. The following items are excluded from the oxygen benefit and are not considered for coverage or appeal under the NIHB Program:

  • oxygen for therapy treatment and/or therapy equipment, such as:
    • pain relief (e.g., migraines, cluster headaches, chronic fatigue syndrome);
    • topical or systemic hyperbaric treatment; and
    • oxygen for angina in the absence of documented chronic hypoxemia.
  • oxygen benefits for outings while the client is an in-patient in an acute or long-term hospital setting;
  • oxygen to run nebulizers/compressors; and
  • oxygen on a “stand-by basis” (PRN).
C. Provider Services to Support Oxygen Equipment and Supplies

To support oxygen therapy the provider is required to offer the following services:

  • complete set-up within 24 hours of authorization (with the exception of ferry and remote site transportation limitations);
  • equipment delivery, safety and care, and client education on use;
  • a respiratory therapist or nurse visit within 72 hours, after three months, and every six months thereafter to ensure optimum oxygen therapy (i.e. review prescription, review use of equipment, educate client on condition); and
  • removal of equipment within 72 hours of being informed that it is no longer required.

Long-term oxygen may be considered by the Program after an applicant's condition has been stabilized and the treatment regimen optimized.

D. If an ABG is not available

Oxygen may be approved for up to three months without an ABG in situations where a client lives 250 km or more from a centre able to perform an ABG test. However, ABG results must be obtained within those three months.

Detailed oximetry strips are required and need to be submitted with the initial prior approval request.
Oximetry testing must indicate an SpO2 of less than 89% for two (2) consecutive minutes at rest, or an SpO2 of less than 90% with written evidence of:

  • cor pulmonale;
  • secondary polycythemia;
  • pulmonary hypertension; or
  • if there is desaturation on exercise or at night.

Note: NIHB will consider waiving the ABG requirement in situations where a client lives in a fly-in zone or area that is away from a centre able to perform an ABG.

3.4.5. Oxygen Equipment and Supplies Benefit Grid

3.5. Pressure Garments and Pressure Orthotics Benefits

3.5.1. Pressure Garments and Pressure Orthotics Benefit Categories

Pressure garments and pressure orthotics benefit are organized in the following categories:

  • Compression garment and lymphedema compression device:
    • custom-fitted graduated compression garment;
    • custom-made graduated compression garment; and
    • lymphedema compression device sequential extremity pump for lymphedema.
  • Hypertrophic scar management:
    • custom-fitted pressure garment;
    • custom-made pressure garment;
    • customized pressure orthosis; and
    • custom-made pressure orthosis.

3.5.2. Prescriber/Provider Requirements

Prescribers:

Compression garments of 20mmHg to 30mmHg, and 30mmHg to 40mmHg, as well as lymphedema compression devices are to be prescribed by a physician or nurse practitioner.

Compression garments over 40mmHg, and all hypertrophic scar pressure garments are to be prescribed by a vascular surgeon, orthopedic surgeon, oncologist, internist, pediatrician, plastic surgeon, physiatrist or general surgeon.

Providers:

To be considered for NIHB coverage, compression garment and lymphedema compression devices must be provided by an NIHB enrolled pharmacist/MS&E provider certified as a compression garment fitter.

Hypertrophic scar pressure garments must be provided by an enrolled NIHB pharmacist/ MS&E provider who is a certified compression garment fitter and a certified burn scar garment fitter.

An employee of the enrolled pharmacist/MS&E provider with certification as a compression or burn scar garment fitter is also acceptable.

3.5.3. Prior Approval Process

Prior approval is required for all pressure garment and pressure orthotic benefits.

To initiate the prior approval process, the NIHB Orthotics-Custom Shoes-Prosthetics-Pressure Garments Prior Approval Form along with to the following supporting documentation are required by the regional office:

  • prescription indicating the required compression;
  • any other information the provider/physician or nurse practitioner may have to support the request; and
  • the required information as described in section 3.5.4.

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3.5.4. Pressure Garments and Pressure Orthotics Benefit Policies

A. Required Information

The following information and criteria are requirements for coverage of pressure garments and pressure orthotics benefits:

a) Compression stocking/sleeve 20-30, 30-40mmHg and high sustained compression bandages 35mmHg

  • client’s diagnosis;
  • prescription indicating the requested compression;
  • qualifications and the title of the fitter;
  • whether the item is custom-fitted or custom-made*; and
  • name of the manufacturer and model of the item.

b) Compression stocking/sleeve 40mmHg and up

  • client’s diagnosis;
  • prescription indicating the requested compression;
  • prescriber’s speciality;
  • qualifications and the title of the fitter;
  • whether the item is custom-fitted or custom-made*; and
  • name of the manufacturer and model of the item.

*Exact client measurements are required for custom-made compression garments.

c) Hypertrophic scar compression garment

  • client’s diagnosis and date of onset;
  • site and extent (i.e. percentage of body affected);
  • qualifications and the title of the fitter; and
  • name of the garment’s manufacturer.

d) Sequential extremity pump and accessories

  • client’s diagnosis and cause of lymphedema;
  • site of the lymphedema;
  • qualifications of the fitter; and
  • name of the manufacturer and model of the item.

A sequential extremity pump can be rented on a trial basis for one month before final purchase; however, the rental fee will be applied to the purchase price.

B. Exclusions

Please note that the general exclusion policy (section 2.2) continues to apply. The following items are excluded from the pressure garments and pressure orthotics benefit and are not considered for coverage or appeal under the NIHB Program:

  • compression garments for short-term treatment such as pre- and post-surgery;
  • pre- and post-medical treatment; and
  • post-traumatic edema.
C. Services included in the price

The following services must be included in the cost of the item to be considered for coverage:

  • initial assessment to determine type of benefit required;
  • measuring body part to manufacture the device in precise measurement;
  • manufacturing the device;
  • dispensing the benefit, including adjustment and fitting; and
  • follow-up visits, as per professional/industry standards.

3.5.5. Pressure Garments and Pressure Orthotics Benefit Grid

3.6. Prosthetics Benefits

3.6.1. Prosthetics Benefit Categories

The prosthetics benefit list covers:

  • breast prostheses;
  • eye (ocular) prostheses;
  • lower and upper limb prostheses; and
  • prosthetics supplies, repairs, parts, and labour.

3.6.2. Prescriber/Provider Requirements

  • Breast prostheses must be prescribed by a physician or nurse practitioner, and provided by a certified mastectomy fitter or by a provider who has a certified mastectomy fitter on staff.
  • Ocular (eye) prostheses must be prescribed by an ophthalmologist, and provided by a member of the National Examining Board of Ocularists (NEBO) certified ocularist.
  • Limb prostheses must be prescribed by a physician and provided by one of the following recognized providers:
    • for limb prosthesis: certified prosthetist CP(c), certified prosthetist orthotist CPO(c) or technicien en orthèses et prothèses (TOP) certified by the Canadian Board for Certification of Prosthetists and Orthotists (CBCPO), TOP certified by l’Ordre des technologues professionnels du Québec (OTPQ) (Quebec Only);
    • for stump socks for a prosthesis: an enrolled NIHB Pharmacy or recognized MS&E provider; or
    • for stump shrinkers: an NIHB enrolled Pharmacy or MS&E provider who has a certified compression fitter on staff.

Note: A new prescription is required should an early replacement be needed due to a change in medical condition. Refer to replacement guideline period.

3.6.3. Prior Approval Process

Prior approval is required for all prosthetic benefits, with the exception of eye prosthesis polishing.

To initiate the prior approval process, the NIHB Orthotics-Custom Shoes-Prosthetics-Pressure Garments Prior Approval Form along with the following supporting documentation are required by the regional office:

  • prescription if required as per replacement policy 3.6.4;
  • medical diagnosis;
  • any other information the provider/physician or nurse practitioner may have to support the request;
  • copy of an Explanation of Benefits (EOB) form from any third-party coverage available to the client (e.g., workers’ compensation board, private insurance, etc.); and
  • additional required information as described in section 3.6.5.

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3.6.4. Replacement Process for Prosthetics

An original prescription* may be used for a replacement request when the: 

  • prosthetic was initially covered by the NIHB Program,
  • item requested addresses the same medical condition as the original item,
  • client’s medical condition remains the same, and
  • replacement is within the frequency guideline.

A new prescription* is required for a replacement when the:

  • client changes providers;
  • client’s medical condition changes; or
  • request is for an early replacement.

*Note: A copy of the prescription and prescriber number must be kept on file at the provider’s office for all prosthetic replacement requests.

3.6.5. Prosthetics Benefit Policies

A. Criteria and Required Information

The following information is required for prosthetics benefit coverage:

a) Breast prosthesis

  • date of surgery (initial request only);
  • left, right or bilateral mastectomy;
  • manufacturer and model number of the breast prosthesis and brassiere; and
  • name of the certified mastectomy fitter.

Note: breast prosthesis is to be dispensed within six (6) weeks from the date of the surgical procedure.

b) Eye prosthesis/scleral shell

  • diagnosis and/or medical reason for the request; and
  • date of the onset.

c) Limb prosthesis-definitive:

  • the date of surgery (initial request only);
  • materials to be used;
  • a detailed assessment (with measurements, when applicable);
  • whether an in-house or external laboratory will be used to manufacture the device;
  • a detailed quote/breakdown of components for the prosthesis; and
  • previous NIHB coverage for devices and repairs.

d) Limb prosthesis preparatory

  • the date of surgery;
  • the materials to be used;
  • a detailed assessment (with measurements, when applicable);
  • whether an in-house or external laboratory will be used to manufacture the device; and
  • a detailed quote/breakdown of components for the prosthesis.
B. Exclusions

The general exclusion policy (section 2.2) continues to apply. The following items are excluded from the prosthetic benefit and are not considered for coverage or appeal under the NIHB Program:

  • Breast prosthesis:
    • temporary or swim prosthesis;
    • silicone implants used in breast reconstruction;
    • breast prosthesis for failed breast reconstruction, when the client has not had a mastectomy or lumpectomy;
    • breast prosthesis for cosmetic augmentation; and
    • silicone nipples.
  • Limb prosthesis:
    • electric and myoelectric prosthesis;
    • a second prosthesis for the same amputation site; or
    • early replacement of a prosthetic that has been used beyond manufacturer specifications (e.g. for weight lifting, or sports).
  • Testicular implants
  • Wigs and hairpieces
C. Services included in the price

The following services must be included in the cost of the item to be considered for coverage:

  • initial assessment to determine type of benefit required;
  • casting of the body part to manufacture the device;
  • manufacturing the device;
  • dispensing, including adjustment and fitting; and
  • follow-up visit(s), as per professional association guidelines.
D. Warranty
  • For breast prosthesis, the warranty must guarantee that the prosthesis will remain satisfactory for fit and defects for a minimum of two years.
  • For eye prosthesis, the warranty must guarantee no charge for necessary adjustments for the initial three months following the final fitting, and a one-year warranty against discoloration and separation of materials. An exception can be made when the client's medical condition changes and prevents a satisfactory fit.
  • For limb prosthesis, the warranty must guarantee against breakage for six months and no charge for necessary adjustments for three months after the final fitting provided that the individual's size or medical condition has not changed significantly.

3.6.6. Prosthetics Benefit Grid

3.7. Respiratory Equipment and Supplies Benefits

3.7.1. Respiratory Equipment and Supplies Benefit Categories

The respiratory equipment and supplies benefit categories are:

  • breathing apparatuses and supplies;
  • respiratory secretion clearance; and
  • tracheostomy supplies and equipment.

3.7.2. Prescriber/Provider Requirements

Respiratory equipment and supplies benefits must be prescribed by a:

  • paediatrician for an apnea monitor;
  • medical specialist such as a respirologist, sleep specialist, or a specialist in internal medicine for a bi-level device, oximeter, or volume ventilator;
  • physician for a continued positive airway pressure (CPAP) machine; or
  • physician or nurse practitioner for a compressor, flutter valve, high humidity compressor, peak flow meter, pep mask, percussor, or drainage board.

These items are to be provided by an NIHB enrolled MS&E provider or appropriate health care staff with regulatory affiliations (e.g. registered respiratory therapist/registered nurse familiar with training in managing respiratory conditions).

Please note: No prescription is required for the replacement of mask, breathing circuit tube, nasal pillow and cushion for the mask for a CPAP machine that is approved for coverage by the NIHB Program for the lifetime of the CPAP.

3.7.3. Prior Approval Process

Prior approval is required for all respiratory equipment and supplies benefits.

To initiate the prior approval process, the NIHB Home Oxygen and Respiratory Equipment and Supplies Benefits Approval Form along with the following documentation are required by the regional office:

  • prescription from a recognized provider as described in section 3.7.2 ;
  • any other medical information the provider/physician or nurse practitioner may have to support the request; and
  • required information as described in section 3.7.4.

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3.7.4. Respiratory Equipment and Supplies Benefit Policies

A. Criteria and Required Information

The following criteria and information is required when requesting respiratory benefit coverage:

A. Continued positive airway pressure (CPAP)
  • Prescription from a physician
  • Clinical information including:
    • Age, sex, height and weight, BMI, sleepiness scale (ESS or SSS);
    • Symptoms of sleep disordered breathing and associated risk factors.
  • Results from a sleep study (one of the following):
    • Level 1 - Standard Polysomnograph (PSG)
      Full baseline and treatment PSG or split night PSG demonstrating diagnosis and response to CPAP or alternative therapy.
      It is recognized that Level 1 PSG testing may not be readily available in some regions. In such cases, level 2 or level 3 can be accepted with the additional clinical information as outlined below.
    • Level 2 - Comprehensive Portable PSG
      Sleep study includes apnea/hypopnea index, saturation, heart rate, and body position with baseline and treatment results obtained during two separate nights.
    • Level 3 - (e.g. Stardust)
      Minimum requirements include recording of ventilation (at least two channels of respiratory movement of respiratory movement and airflow), ECG or heart rate, and oxygen saturation with baseline and treatment results obtained during two separate nights.

Once the NIHB Program authorizes coverage of a CPAP, the device may be rented for up to three months. An interface and headgear are to be purchased for the trial period (mask benefit code 99400180).

Before the purchase of the CPAP is considered, the provider must confirm that the client is compliant with the usage via a downloaded CPAP usage report.

Note: The rental fee of the device is to be deducted from the purchase price.

Exception to CPAP testing criteria

The NIHB Program will consider other testing methods on an exception basis, such as when a diagnostic PSG or other diagnostic testing is the accepted testing or standard of care in a given province/territory.

Auto-titration CPAP monitoring

a) Following the successful completion of a diagnostic PSG, the NIHB Program can extend coverage for the rental of an auto-titration CPAP device for up to a 3-month trial period.

The cost of an interface and headgear (mask benefit code 99400180) is covered for the trial period.

b) Following this trial, the provider is to submit the auto-titration CPAP digital download and an overnight oximetry report interpreted by a physician trained in the diagnosis of sleep disordered breathing for coverage.

The purchase of a fixed pressure CPAP device may be covered if:

  • the data collected from the auto-titration CPAP and the overnight oximetry with CPAP demonstrates significant improvement in the sleep condition;
  • the readout from the auto-titration CPAP shows that the client is compliant with therapy; and
  • the CPAP therapy is supported by the interpreting sleep specialist.

Note: The amount spent on the rental must be deducted from the purchase price of the CPAP.

B. Exclusions

Please note that the general exclusion policy (section 2.2) continues to apply. The following are items excluded from the respiratory benefit and are not considered for coverage or appeal under the NIHB Program:

  • respiratory benefits for outings while the client is an in-patient in an acute or long-term hospital setting;
  • custom-made masks for ventilation; and
  • incentive spirometer or volumetric exerciser.
C. Services included in the price

Items:

  • Rental: Pressure device (CPAP or bi-level) with integrated heated humidifier and circuit (tubing), and all necessary accessories such as filters or connectors
  • Purchase: Pressure device (CPAP or bi-level) with integrated heated humidifier and circuit (tubing)

Services:

  • Product ordering and delivery from manufacturer to provider
  • Initial product set up and mask fitting
  • Instruction on the effective use, care and maintenance of the device
  • All ongoing care including follow-up appointments and calls to monitor effectiveness, support compliance and make necessary adjustments (such as mask re-fit)
  • Report generation
  • Correspondence with NIHB as part of coverage process
  • Correspondence with other health care professionals (physician, sleep lab) as necessary
D. Warranty

Vendor must honour manufacturer’s warranty.

3.7.5. Respiratory Equipment and Supplies Benefit Grid

4. Payment and Reimbursement

4.1. Coordination of Benefits

When an NIHB-eligible client is covered by another public or private health care plan, claims must be submitted to the client’s other health care/benefits plan first. The NIHB Program will then coordinate payment with the other payer on eligible benefit(s). Claim submissions involving coordination of benefits with a third-party health care plan may be submitted manually or electronically.

Manual claims are to be accompanied by 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. If the client no longer has alternate health coverage, a letter from the client or provider (on behalf of the client) is required to confirm the change in coverage.

If the other plan refuses to coordinate with the NIHB Program, the provider may submit the item or service for coverage under the NIHB Program by providing the Health Canada regional office a copy of the health care plan message indicating refusal to coordinate.

In situations where the NIHB Program is coordinating benefits on eligible MS&E items as a secondary payer with another health care plan/program, NIHB will respect the prescribing requirements of the other plan/program. The NIHB Program criteria for coverage will continue to apply.

When the cost of an MS&E item is fully covered through a public/private health care plan, the coordination of benefits will not be required or accepted by the Program. As such, the NIHB Program will not approve requests for a co-payment to upgrade an item.

4.2. Claims Submission

After signing an MS&E Provider Agreement with the claims processor for the NIHB Program, providers are advised to read and retain a copy of the Medical Supplies and Equipment (MS&E) Claims Submission Kit. This Kit outlines provider accountability and obligations when submitting claims for payment. For a copy of the Kit, refer to the Express Scripts Canada website.

4.3. Terms and Conditions of Services

To be eligible for payment of services rendered, providers must adhere to all of the criteria and policies in this guide and Medical Supplies and Equipment Benefits lists, Medical Supplies and Equipment Claims Submission Kit, and the Provider Agreement for Medical Supplies and Equipment.

It is the provider’s responsibility to verify client eligibility for a benefit and to ensure that items are covered under the NIHB Program by seeking prior approval.

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4.4. Unclaimed MS&E Items

A partial reimbursement may be requested for custom-made or special-order items in situations where the client: 

  • does not pick up the item;
  • is unable to use the item; or
  • is deceased.

In such cases, the custom-made item:

  • is dismantled and an invoice is submitted to the NIHB Program for the custom-made parts that cannot be reused, as well as for professional fees incurred for the creation of the item.

In cases, where the item is a special order:

  • an invoice is submitted for any re-stocking fees and shipping costs associated with returning the item to the manufacturer.

Contact the Health Canada Regional Office to initiate this process. In cases where the client does not pick up the item, the provider should make a reasonable effort to contact the client. Each submission will be reviewed on a case-by-case basis.

5. Appendices

A. Acronyms

  • ABG: Arterial Blood Gas
  • ADL: Activities of Daily Living
  • Bi-CROS: Bi-Lateral Contralateral Routing of Offside Signals
  • BTE: Behind-the-Ear
  • CBCPO: Canadian Board for Certification of Prosthetists and Orthotists
  • CO(c): Certified Orthotist
  • CP(c): Certified Prosthetist
  • CPAP: Continuous Positive Airway Pressure
  • CPed(c): Canadian Certified Pedorthists
  • CPO(c): Certified Prosthetist Orthotists
  • CROS: Contralateral Routing of Offside Signals
  • DPM: Doctor of Podiatric Medicine
  • DPodM: Chiropodist (Diploma in Podiatric Medicine)
  • ESS: Epworth Sleep Scale
  • FNIHB: First Nations and Inuit Health Branch of Health Canada
  • HICPS: Health Information and Claims Processing Services
  • INAC: Indigenous and Northern Affairs Canada
  • ITC: In-the-Canal
  • ITE: In-the-Ear
  • MS&E: Medical Supplies and Equipment
  • NIHB: Non-Insured Health Benefits
  • OT: Occupational Therapist
  • OTPQ: Ordre des technologues professionnels du Québec
  • PSG: Polysomnograph
  • PT: Physiotherapist
  • SSS: Stanford Sleep Scale

B. Client Eligibility

To be eligible for NIHB Program benefits, a person must be a Canadian resident and have the following status:

  • registered Indian according to the Indian Act; or
  • Inuk recognized by one of the following Inuit Land Claim organizations: Nunavut Tunngavik Incorporated, Inuvialuit Regional Corporation, Makivik Corporation. For an Inuk residing outside of their land claim settlement area, a letter of recognition from one of the Inuit land claim organizations and a birth certificate are required; or
  • an infant, less than one year of age (1), whose parent is an eligible client; and
  • is currently registered or eligible for registration, under a provincial or territorial health insurance plan; and
  • is not otherwise covered under a separate agreement (e.g. a self government agreement) with federal, provincial or territorial governments.

Please note that the following individuals may be excluded from the NIHB Program, contact the Regional Office for more information:

  • First Nations and Inuit who are not resident in Canada
  • First Nations and Inuit individuals incarcerated in a federal, provincial/territorial or municipal corrections facility
  • First Nations and Inuit individuals who are in a provincially/ territorially funded institutional setting which provides its residents with supplementary health benefits as part of their care, such as nursing homes

Health benefit requests for these individuals should be submitted to the appropriate organization.

To facilitate verification, MS&E providers should provide the following client identification information in each claim:

  • surname (under which the client is registered);
  • given names (under which the client is registered);
  • date of birth (yyyy/mm/dd); and
  • client identification number.

It is recommended that providers ask clients to present their identification card upon each visit to ensure that client information is entered correctly and to protect against mistaken identity.

For recognized Inuit clients, one of the following identifiers is required:

  1. Government of the Northwest Territories health plan number, which begins with the letter "T" and is followed by seven digits. This number is valid in any region of Canada and is cross-referenced to the First Nations and Inuit Health (FNIH) Regional Office client identification number.
  2. Government of Nunavut health plan number, which is a nine-digit number starting with a "1" and ending with a "5". This number is valid in any region of Canada and is cross-referenced to the FNIH Client identification number.
  3. FNIHB Client Identification Number (N-Number), which begins with the letter "N" and is followed by eight digits. This is a client identification number issued by the First Nations and Inuit Health Branch at Health Canada to recognized Inuit clients.

For registered First Nations clients, one of the following identifiers is required:

  1. Indigenous and Northern Affairs Canada registration number, which is a 10-digit number. Also known as the Treaty or Status number, this registration number is the preferred method of identifying First Nations clients.
  2. Band Number and Family Number, where applicable.
  3. FNIHB Client Identification Number (B-Number), which begins with the letter "B" and is followed by eight digits.

For infants under one year of age who are not yet registered with Indigenous and Northern Affairs Canada or applicable Inuit associations, providers communicate with the Health Canada regional office.

Information can also be found in the Medical Supplies and Equipment Claims Submission Kit at Express Scripts Canada website.

C. Privacy Statement

Health Canada's NIHB Program has a responsibility to protect personal information under its control in accordance with the Privacy Act and its 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 on Health Canada’s privacy practices, please contact the Health Canada/Public Health Agency of Canada Privacy Management Division at 613-948-1219 or by email at privacy-vie.privee@hc-sc.gc.ca.

D. Appeal Process

A denial of benefit can be appealed by the client or the provider on behalf of the client. Please note that the items identified as exclusions or insured services cannot be appealed. Refer to appeal procedures online or contact the Health Canada regional office for information

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E. Audit Program

The NIHB provider audit program ensures that the NIHB Program is accountable for the expenditure of public funds. The Health Information and Claims Processing Services (HICPS) contractor performs this audit function by verifying paid claims against records to confirm that the claims have been billed in compliance with the terms and conditions of the NIHB Program.

Detailed information about audit procedures and the responsibilities of providers for these audits are included in the Medical Supplies and Equipment (MS&E) Claims Submission Kit.

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F. Contact Information

For Health Canada Regional Office information, please visit our Contact page.

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