Non-Insured Health Benefits by 2uN3YA3

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									                                 Non-Insured Health Benefits
    The non-Insured Health Benefits Program provides supplementary health benefits, including dental treatment, for
                                      registered Bigstone Cree Nation members




                           Pharmacy
                       Policy Framework




“Our mission is to revive, strengthen and protect members’ treaty right to health”
            NON-INSURED HEALTH BENEFITS (NIHB ) PROGRAM
                          Bigstone Cree Nation

                         BIGSTONE HEALTH COMMISSION




              PHARMACY POLICY FRAMEWORK




This document pro vides important information about the dental benefits available
                       under the Bigstone NIHB Program
                              T ABLE OF C ONTENTS




INTRODUCTION………………………………………………………………………………………………...3
       Foreword…………………………………………………………………………………………………..3
       Framework Objective…….………………………………………………………………………………..3
GENERAL INFORMATION…………………………………………………………………………………….4
       Advance Verification of Eligibility……………………………...……………………...…………….......4
       Provider’s Start and End Dates …………………………………………………………………………...5
       NIHB Provider Number………...…………………………………………………………………………5
BENEFIT POLICIES and PROCEDURES………………………………………………………………………5
       Drugs……………………………………………………………………………………………………....5
       Prescription Quantities…………………………………………………………………………………….6
       Special Promotion/Coupons/Discounts..………………………………………………………………….6
       Limited Use Benefits…………………………………….………………………………………………..7
       Exclusions…………………………………………………………..……………………………………..7
PRIOR APPROVALS………………………………………………………………...…………………………..7
       Drug Exceptions Office……………………………………………………………………………..…….8
       Drug Prior Approval Procedure…………………………………………………………………………...8
COORDINATION WITH OTHER HEALTHCARE PLANS……………………………………………………9
       General Guidelines………………………………………………………………………………………...9
BILLING AND PAYMENT INFORMATION…………………………………………………………………...9
       Billing Methods…………………………………………………………………………………………...9
Claims for Drug Items…………………………………………………………………………………………...10
Point of Service (POS)…………………………………………………………………………………..............10
Pharmacy Claim Form………………………………………………………………………………..………….10
Special Submission Requirement-Infant Claims……… ………………………………………………………..11
Point of Services (POS) Data Elements...………………………………………………………………………..11
Point of Service (POS) Messages and Explanations……...……………………………………………...............13
POS Free Format Messages…………………….………………………………………………………………..15
Point of Service (POS) Reversals………………………………………………………………………………..18
Compounds……..……...………………………………………………………………………………….……..21
Prescription Drugs………………..………………………………………………………………………...……23
Drug Utilization Review (DUR)…………………………………………………………………………………23
       DUR Information Messages…………………………………………………………...………………...23
CPHA Pharmacy Claim Standard Version 3 Intervention Codes…………………………..………………..….24
       Data element Descriptions Client Information…………………………………………………………..24
DATA ELEMENT DESCRIPTIONS……………………………………………………………………………25
       Parent Information……………………………………………………………………………………….25
Claims Payment Options…………………………………………………………………………………………26
Pharmacy Claim Statement………………………………………………………………………………………26
Pharmacy/MS&E Claim Statement Information……………………………….…………..……………………27
Pharmacy Audits…………………………………………………………………………………………………25
DRUG BENETIFS…………………..…………………………………………………………………………..26
       General Information………………………..…………………………………………………….………28
       Drug Benefits………………………..…………………………………………………………………...29
       Drug Benefit Terminology…………………………………………………………………………..…...30
       Extemporaneous Mixtures…….…………………………………………………………………………31
PHARMACY PROVIDER………………………………………………………………………………………32
    Information………………………………...…………………………………………………………….32
    Communication Methods……...…………………………………………………………………………32
FORMS…………………………………………………………………………………………………………..34
    Application Form…..…………………………………………...………………………………………..34
    Pharmacy Claim Form…………………………………………………………………………………...35
    Modifications to Pharmacy Information Form………..…………………………………………………38
                                   Pharmac y Polic y Framew ork
                               Non-Insured Health Benefits Program


INTRODUCTION



Foreword

The Non-Insured Health Benefits (NIHB) Program provides a limited range of medically necessary health-
related goods and services not provided through private insurance plans, provincial/territorial health or social
programs or other publicly funded programs to eligible registered Bigstone Cree Nation members. The benefits
provided under the Bigstone NIHB Program supplement private insurance or provincial/territorial health and
social programs, such as physician and hospital care and community health programs. The benefits funded
include prescription drugs, over-the-counter medication, medical supplies and equipment, short-term crisis
intervention mental health counseling, dental care, vision care and medical transportation to access medically
required health services not provided on reserve or in the community of residence. The NIHB Program also
funds provincial health premiums for eligible Bigstone Cree Nation clients in Alberta and British Columbia.



Framework Objective

The NIHB Pharmacy Policy Framework defines the terms and conditions, policies and benefits under which the
Bigstone NIHB Program will fund pharmacy services for eligible registered Bigstone Cree Nation members.
The Framework sets out a clear definition as to the eligibility of clients, the types of benefits to be provided and
criteria under which they will be found.




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                              Pharmac y Polic y Framew ork
                          Non-Insured Health Benefits Program


GENERAL INFORMATION

    Advance Verification of Eligibility
    Providers may verify client eligibility in advance of providing services by contacting the Bigstone NIHB
    Office toll free at 1-866-891-9719 ext. 4158. They will be asked for the provider idendificat9on
    number, the client’s surname, given name(s), date of birth and client identification number. The benefit
    clerk will verify eligibility based on information given. When client eligibility cannot be verified, the
    client may be referred to the Bigstone Membership office or the Registration Services Unit of the
    Department of Indian Affairs and Northern Development at (819) 994-4028.

    Provider’s Start and End Dates
    Start date is the provider’s start date as a registered NIHB provider. End date is the date the NIHB
    Agreement is terminated. The NIHB or the Provider must confirm termination in writing. Claims with
    a service date subsequent to the end date will not be eligible for reimbursement to the Provider.

    NIHB Provider Number
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