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Prosthetic adn Orthotic Program–Detailed Policy and Procedures

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1. Page 14 of 47 Recipients of Hardship Assistance may qualify for temporary 48 hour PharmaCare assistance The benefits are equivalent to Plan C for that time period For information on Short Term Hardship Benefits refer to Section 10 3 of the PharmaCare PharmaNet Policies and Procedures Manual PharmaCare cannot determine Plan C eligibility Eligibility is determined by the Ministry of Housing and Social Development 4 4 Plan F For Children in the At Home Program Plan F provides eligible benefits at no charge to children who are eligible for benefits under the At Home Program of the Ministry of Children and Family Development The At Home Program provides community based family style care for severely handicapped children who would otherwise become reliant on institutional care PharmaCare covers 100 per cent of the accepted claim amount within acceptable maximums Financial assistance under Plan F does not extend to patients in acute care or extended care hospitals PharmaCare cannot determine Plan F eligibility Eligibility is determined by the Ministry of Children and Family Development 4 5 Fair PharmaCare Monthly Deductible Payment Option PharmaCare offers a Monthly Deductible Payment Option for individuals and families receiving assistance under the Fair PharmaCare plan This payment option benefits families who have high prescription and medical device costs and who expect to meet their deductible during the year
2. Ministry of BRITISH Health COLUMBIA PharmaCare Prosthetic and Orthotic Program Detailed Policy and Procedural Requirements February 2012 Version 2 1 Prosthetic and Orthotic Program Detailed Policy and Procedural Requirements PharmaCare B C Ministry of Health Page 2 of 47 Table of Contents INEFOCUCEION civcncanidcwnennmaawcasaguandinntiawaeedadensienteasennapcuvdedveunuescusantonmaee 7 1 1 How are policies and procedures updated ce eeeee eee ee cece eeeeeeeeeeeeees 7 Contacting Pharma C are ccs cccanevenanuscuecch deaweausesaaantiinadhnetarseanisananiuneneds 8 2 1 PharmaCare Enquiries from Patients e ce eeee cece eee cece eeeeeeeeeeeseeees 8 2 2 Fair PharmaCare Registration csccsesdaccsesvendentasdeseateusoat ied biieanastataswsaees 8 Zea PharmaNet Help DeSK srenrecriicesiorissinierti it tse ret testerit SeT EEDE EE EEEE EE 9 2 3 1 Help Desk Contact Numbers for Health Care Providers eeeeeee 9 2 3 2 Information Required by the PharmaNet Help Desk ceeeeeeeee 9 2 4 Prosthetic and Orthotic Clerk Patient and Practitioner Services 10 2 9 Information SUPDOTE seiss sois mineres s EsP EnEn EE saumarns tienes ves ETEEN REE ESE 10 2 67 Pharmacare WEDSING ssiisssrece i ersroeceinier t inesi t deret TECE EEEE EEEE ES 11 New Health Care Providers ssessssesssseosessossssossesessssoossssosssssseseoo 11 3 14 HOW to Apply eessserss
3. s repair to the device include a copy of the work order cost estimate from the manufacturer plus the actual shipping and or brokerage costs invoices must be available for audit verification 8 1 6 Prosthetic Supplies Prosthetic supplies include items that are either part of the prosthesis or are required to support the proper functioning of the prosthesis such as socks pins locks liners etc Personal hygiene items such as lotions antiperspirants and or cleansers are not PharmaCare eligible benefits You may not claim personal hygiene supplies to PharmaCare as part of a pre approved claim or as a claim under 400 not requiring pre approval 8 2 For Orthoses Maximum reimbursement amounts for orthoses are based on the type of orthosis being fitted The appropriate PIN should be used on all applications and invoices Services related to the manufacture and or repair of an orthosis will be approved based on the health care provider s usual and customary price up to PharmaCare s maximum reimbursement amount as specified in the Reimbursement Schedule for Orthoses see Appendix 5 A basic orthosis includes all clinical labour costs and materials incurred in the creation and dispensing of the orthosis including e Assessing and developing a treatment plan e Measuring and casting e Fitting and alignment e Custom manufacture of a thermoplastic molded orthosis from a positive model obtained by means of a negative cast or use
4. because the patient has not met their deductible 9 4 1 Documents Required Manual claims for Fair PharmaCare Plan B Residential Care Plan C Income Assistance or Plan F At Home Program must include e aPharmaCare Invoice identifying the product or service identified by applicable PIN the approved PharmaCare cost being claimed and for patient submission s only a health care provider s invoice identifying the items dispensed the cost paid and the applicable PINs for each item invoice should be marked PAID IN FULL and e acopy of the patient s PharmaCare pre approval letter or form The PharmaCare Prosthetic Benefits Invoice and Orthotic Benefits Invoice forms and instructions on how to complete them are available online from the PharmaCare website at www health gov bc ca pharmacare suppliers html 9 4 2 Zero Payment Letters If a Fair PharmaCare patient has not met their annual deductible or family maximum when a claim is processed some or all of the eligible claim amount will accumulate toward the patient s deductible PharmaCare will pay for the appropriate portion above the patient s deductible and or family maximum If the PharmaCare portion of a Fair PharmaCare claim is 0 00 because the patient has not met their deductible PharmaCare will send the health care provider a zero payment letter Page 28 of 47 In this case the health care provider will need to obtain payment from the
5. respect to manufacture or repair of the device is free from defect for a period of 90 days from time of dispensing 8 1 2 Other Prosthetic Procedures Maximum reimbursement amounts for an hourly rate and various standard prosthetic procedures excluding definitive sockets as above have been included in a Reimbursement Schedule for Prosthetic Procedures excluding definitive sockets available at Appendix 3 Pricing for procedures will be reimbursed at the health care provider s usual and customary price up to PharmaCare s Maximum Reimbursement Many of the procedure amounts Page 23 of 47 include the cost of some small components and the labour required to complete the procedure PharmaCare coverage is limited to one check test dynamic or diagnostic socket per definitive socket 8 1 3 Component pricing Maximum PharmaCare reimbursement amounts for components is calculated according to the Girling Formula This formula is based on a percentage markup on the list cost of the item The Girling Formula is available at Appendix 4 The Girling Formula can be used for items purchased outside of Canada The list price is adjusted to Canadian dollars and then the second column of the Formula imported item mark up is used to allow for additional freight and duty costs 8 1 4 Exchange Rate on Components Purchased Outside Canada United States US exchange rates are reviewed regularly and adjusted as needed based on the posted cl
6. AFO consists of a calf cuff that tapers to a narrow band behind the ankle the leaf and widens back out to capture the heel and extend to the tip of the toes e Chevron describes the shape of the posterior reinforcement of the dual layer AFO e The principle of the AFO is ESR energy storage and return 1 400 77123512 Hip Abduction orthosis Child s brace e Note that the following orthoses are NOT PharmaCare benefits o Dennis Browne boots and or bars Congenital Dislocation of Hip CDH hip dysplasia e Must be custom fit to patient or to patient model e Will be used only for very young children infants e This would include the following types of orthoses o Wheaton Brace o Pavlik Harness o Rhino Rhino Cruiser cruiser up to 3 years o Von Rosen by approval Page 43 of 47 PIN Type of Orthosis Description Maximum Abbreviation Reimbursement Standing Walking and e Used generally for Cerebral Palsy by approval Sitting Hip Orthosis patients SWASH Must be custom fit to patient or to patient model e Should be determined by a Team Assessment Legg Calve Perthes e Must be custom fit to patient or by approval Disease patient model e This would include the following types of orthoses o Scottish Rite 77123513 Knee ankle foot orthosis e Shells must be made from high 1050 for knee rigid ankle Child s brace temperature plas
7. Assistance form The application should include all relevant documentation including prescriptions and instructions from the physician where available Applications for Financial Assistance forms that are incomplete or that have Worn out First Prosthesis etc as the rationale for replacement will not be processed and will be returned to the health care provider for more information and resubmission Note If the Weight Referring Physician and Other Agencies Involved boxes are not completed the application will be considered incomplete Page 18 of 47 7 2 1 Supporting Documentation for New Amputee Prosthesis For a new amputee First Prosthesis or Primary Amputee is not a sufficient reason for providing a prosthesis Justification should be based on the patient s health needs and expected outcomes For example you should also include relevant information on your patient including but not limited to the following e What did you do to determine that the patient will be a successful prosthetic user e Who did the assessments Was a Team involved e Information regarding cognition e Information regarding gait and mobility e g mostly required for home use or community use only required for transferring e ls the patient returning to work or being retrained e Changes to the patient that affect fit i e changes in height weight and or limb size and e Are there spec
8. BC PharmaCare write to Manager Operational Services 716 Yates St Victoria BC V8W 1L4 Contact Information Support for notification of changes to manager ownership operating name or address and for PharmaNet connections changes to software or relocations e By fax at 250 405 3599 or e By e mail at Informationsupport hibc gov bc ca 2 6 PharmaCare Website The PharmaCare website www health gov bc ca pharmacare offers comprehensive information on a variety of topics including e PharmaCare plans e PharmaCare programs e Fair PharmaCare online registration e Forms e Information sheets e PharmaCare assigned Product Identification Numbers and e PharmaCare Newsletters and PharmaNet Bulletins 3 New Health Care Providers 3 1 How to Apply Write Information Support to apply to BC PharmaCare see Section 2 5 above All applications must include the following information e Business name e Business address e Business phone number e Business fax number e Site manager s name e Names of the directors for the company e Copy of current business license e Certificate showing Canadian Board for Certification of Prosthetists amp Orthotists CBCPO accreditation ocularists or fitters certificate as appropriate See Section 3 2 below and Page 11 of 47 e f connecting to PharmaNet you must also provide information regarding which approved compliance tested software for PharmaNet you will be using see S
9. Page 39 of 47 APPENDIX 3 Reimbursement Schedule for Prosthetic Procedures excluding Definitive Sockets Additional prosthetic procedures have been limited to a PharmaCare maximum reimbursement as set out in the following table Pricing for procedures will be reimbursed at the health care provider s usual and customary price up to the PharmaCare maximum reimbursement amount specified below Immediate Post Operative Prosthesis can be billed separately or it can be included with the first Application for Financial Assistance completed for the patient s first prosthetic device PharmaCare coverage is limited to one check test dynamic or diagnostic socket per laminated definitive socket Procedure Maximum Reimbursement Burgess cast initial with pylon foot forkstrap amp waistbelt 705 Burgess cast change 605 Cast rigid 300 Cosmesis endoskeletal finish Trans tibial TT 455 Cosmesis endoskeletal finish Trans femoral TF 850 Hourly Rate 120 Immediate Post Operative Prosthesis IPOP 1 125 Liner Fit and trim pair only when replacing liners and not the 60 definitive socket Liner Pelite 350 Liner Pelite and leather 450 Liner Pelite leather and PPT 550 Liner Trans femoral TF thermolyn with valve 600 Loaner Foot 50 Loaner Knee 100 Prosthetic Glove install 60 Shuttle Lock Procedure d
10. accurately track what is being provided Here are some sample descriptions for reference e Shoe insert with longitudinal arch toe filler e Molded socket ankle height toe filler e Molded socket PTB height toe filler e Molded socket plastic ankle height toe filler e Molded socket leather ankle height toe filler e Molded socket silicone ankle height toe filler Additional information such as the type of foot plate or any additional components being supplied may also be listed 7 3 Review of Applications for Financial Assistance PharmaCare s Prosthetic and Orthotic Committee reviews all Applications for Financial Assistance taking into consideration e whether the device service is in keeping with PharmaCare s mandate and policies e the cost of the device service requested i e least costly equally effective e the devices services previously approved for the patient from the patient file e warranty coverage for the devices and e replacement periods Applications are reviewed to ensure they meet PharmaCare policy and are therefore eligible for funding assistance The health care provider is responsible for ensuring that the parts dispensed are safe for the patient e g special heavier components required for patients over 220 pounds Careful consideration should be taken in determining what components are provided to the patient to ensure the components will meet the patient s basic functionality re
11. date on the letter or form 7 1 Application for Financial Assistance Process Pre Approval Mandatory You must obtain pre approval on an Application of Financial Assistance form on behalf of your patients for any claims of 400 or more manual or online for coverage under PharmaCare s Prosthetic and Orthotic Program Application forms are available from the PharmaCare website at www health gov bc ca pharmacare suppliers html In addition written requests for pre approvals must be submitted on the PharmaCare Prosthetic Benefits Non Limb Application for Financial Assistance for e replacements of breast prostheses before the two year limit even if less than 400 and e exceptions to be considered on mastectomy prostheses and supplies Complete the appropriate Application for Financial Assistance form describing fully the prosthesis or orthosis being requested and the reasons why it is required The application form must be signed by both the certified health care provider and by the patient Indicate on the form if the application is on behalf of a patient who is a resident of a licensed residential care facility Plan B Page 17 of 47 Approval letters forms provide the Plan information of the patient at the time the Application for Financial Assistance was received and may be subject to change at any time You should verify the patient s Plan information with the patient when fitting of the device is complete to e
12. of computer assisted imaging design and milling e Educating the patient about the orthosis on its general maintenance and care and proper fit e Assessing function and patient orthotic interface and e 90 day health care provider warranty warrant that all material and workmanship with respect to manufacture or repair of the device is free from defect for a period of 90 days from time of dispensing 8 3 For Ocular Prosthesis Services related to the manufacture and or repair of an ocular prosthesis will be reimbursed based on the approved fee as identified on the approval letter or form The maximum Page 25 of 47 reimbursement amount will be 2 000 per ocular prosthesis with an additional 100 available for patients who require additional fitting time due to their unique circumstances Any exceptions to this maximum reimbursement amount should include a detailed explanation providing rationale for any additional material or time required 8 4 For Mastectomy Products Maximum reimbursement amounts for mastectomy products have been included in a Reimbursement Schedule for Mastectomy Products available in Appendix 6 The appropriate PIN should be used on all applications and invoices 9 Claims 9 1 Submission of Claims after Mandatory Pre Approval Received Submit your claim to PharmaNet e Within the six month time limit on the approval letter form for all claims of 400 or more and e After all the work service is com
13. on the PharmaCare website at www health gov bc ca pharmacare publications html 4 2 Plan B For Permanent Residents of Licensed Residential Care Facilities Plan B provides assistance to British Columbia residents of residential care facilities excluding extended care acute care multi level and assisted living facilities that are licensed under the Community Care and Assisted Living Act PharmaCare pays the full cost of eligible prescription drugs and certain medical supplies for Plan B beneficiaries Short term also called respite or swing patients in a long term care facility are not eligible for Plan B Short term residents receive financial assistance under Fair PharmaCare or Plan C depending on the individual s PharmaCare plan eligibility Note Pharmacies health care providers billing for Plan B costs should refer to documentation provided by their software vendor 4 3 Plan C For People Receiving B C Income Assistance Plan C provides PharmaCare financial assistance to British Columbia residents who are eligible for either basic or enhanced medical benefits through the Ministry of Housing and Social Development Under Plan C PharmaCare covers 100 per cent of the accepted claim amount within acceptable maximums Plan C eligibility is provided in real time by the Ministry of Housing and Social Development offices and is in effect from the time received on PharmaNet It cannot be provided retroactively
14. or lower without additional clinical justification being required 8 Maximum Reimbursement Amounts 8 1 For Prostheses Services related to the manufacture and or repair of a prosthetic device are reimbursed based on the health care provider s usual and customary price up to PharmaCare s maximum reimbursement amounts as follows 8 1 1 Definitive Sockets Prosthetic procedures related to the dispensing of a definitive socket are reimbursed based on the type level of socket being fitted The appropriate Product Information Number PIN should be used on all applications and invoices Pricing approvals are based on the health care provider s usual and customary price up to PharmaCare s maximum reimbursement amount as identified in the Reimbursement Schedule for Definitive Sockets available in Appendix 2 A definitive socket includes all clinical labour costs and materials incurred in the creation and dispensing of the socket including e Assessing and developing a treatment plan e Measuring and casting e Fitting and alignment e Custom manufacture of a definitive socket from a positive model obtained by means of a negative cast or use of computer assisted imaging design and milling e Educating the patient about the prosthesis on its general maintenance and care and proper fit e Assessing function and patient prosthetic interface e 90 day health care provider warranty warrant that all material and workmanship with
15. patient or the patient s private insurer Whenever a zero payment letter is sent to you please advise the patient to submit a paid receipt to PharmaCare so that the PharmaCare benefit can be added to their patient record Note Health care providers may contact HIBC see Section 2 3 1 to confirm that a patient has registered for Fair PharmaCare however under the Freedom of Information and Protection of Privacy Act HIBC cannot divulge financial information about patients Only the patient can elect to advise you of their deductible or family maximum Patients can provide this information verbally or by presenting their Confirmation of Assistance form Patients may contact HIBC see Section 2 1 to confirm their registration deductible and family maximum 9 5 Where to Send Completed Claims Submit manual claims by Fax 250 405 3587 or Mail PharmaCare P O Box 9655 Stn Prov Govt Victoria BC V8W 9P2 10 Payment All health care provider claims both manual and online are processed on PharmaNet The Ministry of Finance then issues payments to the health care provider weekly for accepted claims To receive payment by direct deposit complete a BC Government Direct Deposit Application Submit the application and an original void cheque to PharmaCare P O Box 9655 Stn Prov Govt Victoria BC V8W 9P2 The Direct Deposit Application is included in the PharmaCare documents package see Appendix 1 If the health care provider r
16. 880 1 701 1 800 25 1 105 2 905 25 3 005 1 801 1 900 25 1 130 3 030 25 3 130 1 901 2 000 25 1 155 3 155 25 3 255 2 001 2 100 25 1 180 3 280 25 3 380 2 101 2 200 25 1 205 3 405 25 3 505 2 201 2 300 25 1 230 3 530 25 3 630 2 301 2 400 25 1 255 3 655 25 3 755 2 401 2 500 25 1 280 3 780 25 3 880 2 501 2 600 25 1 305 3 905 25 4 005 2 601 2 700 25 1 330 4 030 25 4 130 2 701 2 800 25 1 355 4 155 25 4 255 2 801 2 900 25 1 380 4 280 25 4 380 2 901 3 000 25 1 405 4 405 25 4 505 etc The partial 100 is worked out at the percentage rate for the next 100 increment Example 1 To calculate the cost out amount for items with a catalogue price of below 500 multiply the price by two For the imported items with a Canadian dollar price of below 500 multiply the amount by 2 2 to allow for the brokerage and extra freight charges Example 2 For an item that costs 788 From the chart go to line 601 700 percentage markup is 85 so cost out is 1 380 for the first 700 To calculate the 88 go to the next line down 701 800 for the percentage mark up which is 75 So 75 of 88 is 66 Add the 66 to the 88 and to the 1 380 and you determine the total cost of 1 534 Page 41 of 47 APPENDIX 5 Reimbursement Schedule for Orthoses Reimbursement for orthoses are based on type The appropr
17. Bulletins are produced in a consistent format are numbered consecutively by year and dated Page 7 of 47 Future PharmaCare Newsletters and PharmaNet Bulletins will contain updates that supersede the PharmaCare and PharmaNet policies and procedures outlined in this manual PharmaCare Newsletters and PharmaNet Bulletins are available on the PharmaCare website www health gov bc ca pharmacare publications html PharmaCare provides an e mail subscription service for pharmacies health care providers and stakeholders who wish to be notified when a new PharmaCare Newsletter or PharmaNet Bulletin is posted to the PharmaCare website You may also subscribe to receive PharmaNet alert notifications for your area of the province To subscribe please visit the website and complete the brief online form Updates to the PharmaCare PharmaNet Policies and Procedures Manual may also be issued periodically Each update will be accompanied by a summary of any substantive changes 2 Contacting PharmaCare Health Insurance British Columbia HIBC administers the PharmaCare program on behalf of the Pharmaceutical Services Division Ministry of Health HIBC can answer questions about both PharmaCare and the Medical Services Plan For information related to pharmacy health care provider practices refer to the PharmaCare PharmaNet Policies and Procedures Manual under Chapter 2 and for information on Troubleshooting for PharmaNet problems refer to PharmaC
18. DIX 2 Reimbursement Schedule for Definitive Sockets Reimbursement for prosthetic procedures resulting in the provision of a laminated definitive socket is based on the type level of socket being fitted The appropriate PIN should be used on all applications and invoices For additional information about reimbursements for definitive sockets refer to Section 8 1 1 above PIN Prosthetic Level Maximum Left Right Reimbursement LOWER BODY 77123207 77123190 Trans metatarsal TM by approval 77123402 77123396 Trans tarsal TC Note includes Lisfranc Tarso Metatarsal and Chopart Mid Tarsal 1 700 77123384 77123372 Symes SY 2 880 77123360 77123347 Trans tibial TT 2 760 77123526 77123527 Rotationplasty RP Note includes Van Nes 3 160 77123487 77123475 Knee Disarticulation KD 4 140 77123359 77123335 Trans femoral TF 3 740 77123524 77123525 Proximal Femoral Focal Deficiency PD 4 200 77123440 77123438 Hip Disarticulation HD 4 370 77123522 77123523 Hemipelvectomy HP 4 485 UPPER BODY 77123505 Hand Prosthesis PH by approval 77123518 77123519 Wrist Disarticulation WD 2 650 77123281 77123268 Trans radial TR 2 300 77123520 77123521 Elbow Disarticulation ED 3 220 77123270 77123256 Trans humeral TH 2 800 77123463 77123451 Shoulder Disarticulation SD 3 570
19. Once enrolled families pay their Fair PharmaCare deductible in monthly installments and receive PharmaCare assistance with eligible costs right away Families are eligible for this payment option if they e are registered for Fair PharmaCare e do not have private health insurance with a drug benefit plan and e have a deductible greater than 0 Patients may enroll in the Monthly Deductible Payment Option for the current calendar year any time up to September 30th After September 30th patients can request enrollment for the following year Page 15 of 47 For more information or to enroll please have your patients contact HIBC at e Vancouver Lower Mainland call 604 683 7151 and e from the rest of British Columbia call toll free 1 800 663 7100 A patient information sheet regarding this payment option is also available on the PharmaCare website at www health gov bc ca pharmacare publications html Enrolling in the Monthly Deductible Payment Option is not permitted if a patient has private health insurance with a drug benefit plan The private health insurer contributes towards this patient s prescription costs and the Monthly Deductible Payment Option could complicate or delay the reimbursement of the patient s private health benefits 5 Manager Operating Name Ownership Address Change Notify Information Support see Section 2 5 above to obtain a BC PharmaCare Non pharmaceutical Supplier Participation Agreement whi
20. PHN CareCard number e full name e address e gender and e invoice number if applicable When calling regarding a practitioner you should have the following practitioner information ready e full name e address e Medical Services Plan MSP Billing Number preferably if known or Practitioner ID if Known and e gender 2 4 Prosthetic and Orthotic Clerk Patient and Practitioner Services The Prosthetic and Orthotic Clerk is the point of contact for Applications for Financial Assistance A Clerk is available from 8 30 AM to 4 30 PM Monday to Friday Contact the Prosthetic and Orthotic Clerk to e Request the status of a patient s current Application for Financial Assistance e Request information about a patient s old over 6 months Application for Financial Assistance e Request other information regarding a patient s Application for Financial Assistance and e Provide additional information to the Prosthetic and Orthotic Committee regarding a patient s Application for Financial Assistance Contact the Prosthetic and Orthotic Clerk e By phone at 250 405 4251 or e By fax at 250 405 3590 2 5 Information Support Information Support is the point of contact for new applications changes to manager ownership operating name or address and for PharmaNet connections A Customer Service Representative will be available from 8 30 AM to 4 30 PM Monday to Friday Page 10 of 47 For a new application to
21. PharmaCare plan e enquire about the status of PharmaCare claims or e request set up for a Plan B patient s claim for an approved Application for Financial Assistance Enquiries about the status of a patients Application for Financial Assistance will be handled by the Prosthetic and Orthotic Clerk Patient and Practitioner Services HIBC see Section 2 4 below 2 3 1 Help Desk Contact Numbers for Health Care Providers Call the PharmaNet Help Desk at HIBC e Vancouver Lower Mainland 604 682 7120 or e Rest of British Columbia call toll free at 1 800 554 0225 You will be greeted by a message and offered the option of accessing the PharmaCare Information Line an automated information system for pharmacists speaking directly to a PharmaNet Help Desk customer service representative or speaking directly to Patient Restrictions When prompted press 2 to speak directly to a customer service representative Important The contact numbers above are for pharmacies and health care providers only Patients should use the numbers provided in Section 2 1 above 2 3 2 Information Required by the PharmaNet Help Desk When calling the PharmaNet Help Desk be prepared to provide the following information e your pharmacy equivalency code PEC e your name and e a brief description of the problem Page 9 of 47 When calling regarding a patient you should also have the following patient information ready e Personal Health Number
22. al Supplier Participation Agreement see Section 3 1 above Out of province health care providers cannot connect to PharmaNet Out of province health care providers will be required to submit manual claims to PharmaCare in the same way as in province non pharmaceutical suppliers that are not connected to PharmaNet see Section 9 4 below 4 PharmaCare Plans and Programs Available PharmaCare payments are determined by the rules and deductible requirements under the patient s PharmaCare plan For a complete listing of PharmaCare plans and detailed information on each refer to the PharmaCare PharmaNet Policies and Procedures Manual under Chapter 8 Page 13 of 47 4 1 Fair PharmaCare The Fair PharmaCare plan provides B C residents with coverage for eligible prescription drugs and designated medical supplies Fair PharmaCare assistance is based on a family s net income as reported to the Canada Revenue Agency Individuals and families must register with PharmaCare to receive their maximum Fair PharmaCare financial assistance Individuals or families who are registered with the Medical Services Plan but who do not register for Fair PharmaCare are automatically assigned the highest deductible of 10 000 per person For more information regarding Fair PharmaCare visit the PharmaCare website or refer to the PharmaCare PharmaNet Policies and Procedures Manual A patient information sheet regarding Fair PharmaCare is also available
23. and RepairS ccc cceccc cece eeeeeeeeeeeeeeeees 24 8 1 6 Prosthetic SUPP NGS wine voereeseveeree tt ssri s t reren oE tee ee bt E 25 8 2 F r OrthOSES sixes ciangie bs sehen eines EESE n ENEE EEEE NETEDE ESES RETENCNE ES 25 8 3 ForOcu lar Prosthesis seios vecse irise riie EE ETTE 25 8 4 For Mastectomy Products ssssesssssessssesssscesssscessseeessesesesceseeeeesse 26 Claims osesssrssniero noosus eenden a e aa a a aa 26 9 1 Submission of Claims after Mandatory Pre Approval Received 06 26 Page 4 of 47 9 2 Financial Control in PharmaNet cece cscs ccccceccecccccceccecceeseeeccecs 26 9 3 CONUS CLAIMS xss255dce secu betrannennerwapieeararen si dswiarentualeneneavaisemeatiantdasaews 27 9 3 1 Online Claims for Residents of Residential Care Facilities 27 9 4 Man al ClAlIMS s 0caiscteeneseeieancnasaatssaantawsdaesscaanbeetesues mi E EEEE EEEE ees 28 9 4 1 DOCUMENTS Required sricssrsirsesrre stis trict r aC ns Caren ES INE SEESE EEE 28 9 4 2 Zero Payment Letters ccc cece cece ee eeeeeeeeeeeeeeeeeeeeeeeeeeeeeees 28 9 5 Where to Send Completed Claims sissies svissewsneesdedt oareeweuurvesdiweasaveavasaaes 29 10 Payment overscdannsedanawnedsiiwaniiedaiiess enslaved vaasunwoemeeearedssioaduinieeniedeinenen 29 10 1 Payment for Manual Claims dieiacavisnssosnuveiaeasabes tacasdedneusiees sensurransexansee 30 10 2 Payment for Online Claims snscsava cele csseeudiosndceucanrn
24. are PharmaNet Policies and Procedures Manual under Chapter 7 2 1 PharmaCare Enquiries from Patients The public may contact a Customer Service Representative at HIBC regarding PharmaCare policies from 8 00 AM to 8 00 PM Monday to Friday and from 8 00 AM to 4 00 PM on Saturday at the following numbers e Vancouver Lower Mainland 604 683 7151 or e Rest of British Columbia call toll free 1 800 663 7100 Your patients should use one of these numbers to contact HIBC about e the status of their Fair PharmaCare registration or e questions regarding the Prosthetic and Orthotic Program 2 2 Fair PharmaCare Registration All British Columbians are encouraged to register for Fair PharmaCare B C residents can register e Online at www healthservices qov bc ca pharmacare This service is available 24 hours a day 7 days a week e By contacting HIBC at the telephone numbers provided in Section 2 1 above Page 8 of 47 2 3 PharmaNet Help Desk The PharmaNet Help Desk is a health care provider s first point of contact for PharmaCare and PharmaNet enquiries The Help Desk is available 24 hours a day 7 days a week including all statutory holidays except Christmas Day See PharmaCare Bulletins for details on holiday hours Telephone the PharmaNet Help Desk to e order additional copies of PharmaCare forms or brochures When ordering you will be asked to provide your pharmacy equivalency code PEC e determine a patient s
25. are Providers Some patients are dissatisfied with either the health care provider or the product that was supplied and as a result may switch to a different health care provider for service even though the replacement period is not complete Page 21 of 47 These patients are still subject to the same PharmaCare coverage rules even though their health care provider has changed For example they are still only entitled to one prosthesis every three years or one orthosis per year If a patient chooses to switch to a new health care provider PharmaCare will consider a new application but the patient should not expect that they will be entitled to a new device For instance PharmaCare may consider the provision of a new socket if it is warranted but the new prosthetist will be required to reuse all the other components 7 8 Liners Applications for Financial Assistance applications submitted for pre approval should be based on PharmaCare policy and component choices within the application should reflect the Basic Functionality and Lowest Cost Device policies with any exceptional requests supported by sufficient justification and documentation to explain the need for a more costly component Basic functionality liners include e pelite liners e thermoplastic elastomer liners i e Alps Silipos or Alpha and e co polymer liners i e Otto Bock TPE or Balance TPE Liners that exceed the basic functionality guidelines inclu
26. armaCare PharmaNet Policies and Procedures Manual Section 6 7 11 2 Audit Program As stated in the Non pharmaceutical Suppliers Participation Agreement health care providers shall upon the request of a duly authorized government representative of the PharmaCare Program supply all relevant information for the purposes of audit Page 32 of 47 11 2 1 Selection Process Health care provider audit selection is by analysis of data and information by geographic random methods or by tips Regardless of the method of selection the PharmaCare Audit Review Committee PARC from the Ministry of Health must approve all audits For information on this Committee refer to the PharmaCare PharmaNet Policies and Procedures Manual Section 6 7 2 Other information received concerning a health care provider s claims practice is carefully reviewed with respect to data analysis reports 11 2 2 Health Care Provider Notification Formal notice of an audit is normally provided A notification letter including the appointment letter of the auditors as duly authorized government representatives is sent by courier to the health care provider to confirm audit dates A follow up phone call from the Audit Manager or lead auditor will occur a few days before the arrival date to confirm arrangements 11 2 3 Confidentiality The confidentiality of the information used for the audit is guaranteed by the public service Oath of Employment taken
27. by the auditors when hired as government employees Once they arrive at a health care provider the auditors and the site manager complete a Health Care Provider Designated Support Person Confidentiality Undertaking form For more information refer to the PharmaCare PharmaNet Policies and Procedures Manual Section 3 2 Confidentiality Undertakings 11 2 4 Records and Documentation Auditors must be permitted at all reasonable times access to the health care provider s site or other location where the records are located to inspect and copy or to remove those records for the purpose of copying and to conduct an audit of those records related to claims paid in whole or in part by PharmaCare In the event that the audit team removes any such records from the health care provider s site or the location where the records are located the records will be returned within 20 business days except for prescription records which will be returned within 5 business days Note The audit team will complete a Temporary Removal of Documents form with the health care provider manager when records are removed Upon request the health care provider must inform the auditors of the location of the records if not kept at the health care provider site If records are located out of province they must be provided for audit within 20 business days Page 33 of 47 In the event the health care provider is under audit at the time that any three yea
28. ch is to be signed if any one or more of the following changes are made e Change in health care provider site manager e Change in operating name or e Change in ownership A Direct Deposit Application form may be required to be completed if there has been a change in ownership or banking information Information Support can provide the appropriate document Health care providers do not need to sign a BC PharmaCare Non pharmaceutical Supplier Participation Agreement for a correction or change of address 6 Connecting to PharmaNet Connection to PharmaNet is not mandatory The benefits of connecting to PharmaNet are e Claims on PharmaNet adjudicate in real time providing immediate information on the portion of a claim to be paid by the patient and the portion if any covered by PharmaCare e Not having to submit paper forms for claims under 400 or for claims that have been pre approved by PharmaCare and e Eliminating the two to three week turnaround time required for processing manual claims and issuing payment Note PharmaNet access allows you to submit online claims but does not allow you to access your patient s full medication history It normally requires 50 business days excluding statutory holidays to set up a new site with a PharmaNet connection Page 16 of 47 You must use approved compliance tested software to connect to PharmaNet A list of approved software vendors software service organizations is pro
29. cvecsesdteasvesatsiiobndiuaes 30 10 3 Claims Rejected by PharinaCar viinssdivesssauexd exaadicadnosubwbiveadeeessaaenvancded 30 10 4 Incomplete or Incorrect ClalIMSs cecsecsevessedsckvxvecsaxeiscesadeenexeavens easaviocsen 30 10 5 PharmaGare Enquiry Letters jicasccsasadarcceactedaateasaeeativares ied yaaewbisieeesesss 31 10 6 Health Care Provider s Role in Assisting Patients Submitting Manual Claims 31 10 7 Patient s Deductible Not Yet Reached ccccssccecscscccsscccscecesseseesses 32 11 Audit scuscasaisctiawssanccunanaadaiwapennndeanancsieupeawiwsans aE nE E aO 32 11 1 Pharmacare Audit sssisssciserssseiviiseriruerdeseisersevoivenss ierte isriisvendeisavereet 32 11 2 AUGIC PIOGPAM ussu02desssueenewianssanseaacdewsvesye diate ECETES AEE EET E r ET 32 11 2 1 Selection PROCESS 4 sag sosyvaxesnvcpew sansa is niEes EEEE E EES 33 11 2 2 Health Care Provider Notification scscssssccssssccccssceveseveceees 33 11 2 3 Confidentiality vas sod viene ga Senuee oris tin aE EEEE E eed 33 11 2 4 Records and Documentation cccccscvereseccccesscccecscsevesecesenes 33 WAZ Audit SCOPE occ rssenacdrendedsas ane cass seoawaverenenatereeiovnanenenncenenreaeapers 34 11 2 6 Draft Audit Report lt ssscsrscsaccvseeesatesacrasuweber ener sateokeseeieenassavannenta 34 11 2 7 JFinall AUGIE REDON ocavecicviucsutdetanousewievdentvewenviensexesaowneveusensavesd 35 11 2 8 Alternative Dispute Resolution cccceesesscccccceeessssccccee
30. de e silicone liners i e Iceross Comfort or Otto Bock Silicone Gel e urethane liners i e Otto Bock s Simplicity e custom made liners i e TEC and e seal in liners i e lceross Derma or Stabilo Liners that are requested that exceed the basic functionality guideline will require appropriate justification Justification can include but is not limited to e information supplied by the prescribing prosthetist e documentation from a physiatrist physician dermatologist plastic surgeon or wound care specialist i e medical reports and prescriptions or e medical documents that corroborate the need for a change in the liner i e cite the liner as the cause of the condition The guideline will be grandfathered for existing patients This will allow special consideration to patients who currently have a liner which is not one of the basic functionality liners listed above Appropriate documentation must accompany each application to show why it is important to keep the patient in their current type of liner and why the exception was made Note Although silicone liners are not considered to be basic functionality there are some silicone liners that are priced comparable to basic functionality liners and the liner of choice for some prosthetists So on an ongoing exceptional basis PharmaCare will approve applications including any liner that is priced Page 22 of 47 comparable to a basic functionality liner i e same price
31. de from high temperature plastic Must be custom fabricated from patient model The SMO is molded and then a different type of AFO is molded over the top of the SMO they can then be worn separately or together i e SMO for circle time or floor play and AFO with SMO for walking 1 200 for rigid 1 400 for articulated Page 42 of 47 PIN Type of Orthosis Abbreviation Description Maximum Reimbursement 77123511 Ankle foot orthosis AFO patella tendon bearing PTB ground reaction Child s brace Note This PIN also includes Chevron and Double wrap AFOs e Must be made from high temperature plastic e Must be custom fabricated from patient model e Extends from below the knee down to and includes the foot e Ankle joint may or may not be included depending on type of orthosis 1 200 for rigid 1 400 for articulated Chevron or Double wrap PTB e Must include both a posterior and an anterior shell double mold e Must be used to offload weight from below the knee i e tibia fibula or ankle joint 1 200 for rigid 1 400 for articulated Anti crouch ground reaction e Must include both a posterior and an anterior shell double mold e Must be used to limit or assist in controlling dorsi flexion and assist in controlling knee extension 1 200 for rigid 1 400 for articulated Chevron Double Wrap e A posterior leaf spring PLS style
32. dors provide software specific training on submitting claims to PharmaNet Online claims must be submitted on PharmaNet using the PINs assigned by PharmaCare These PINs are available at www health gov bc ca pharmacare pins prospins html When processing claims on PharmaNet e Enter the intervention code MO for all claims between 500 00 and 999 99 and MP for all claims between 1 000 00 and 9 999 99 e All claims that exceed 9 999 99 must be split and submitted as separate claims of 9 999 99 or less e Inthe Prescriber ID field enter the referring physician s Practitioner ID assigned by the College of Physicians and Surgeons of BC For unusual cases where there is no referring physician i e supplies have been dispensed by the prosthetist orthotist or small repairs have been made you may enter your Practitioner ID assigned to you by the College of Pharmacists of BC Remittance Advice Forms are sent to online health care providers only when a payment adjustment is made To access payment data except payment adjustment information on PharmaNet use the Retrieve Daily Totals TDT transaction All health care provider software vendor products contain a feature for retrieving daily totals although it may be named differently Please consult your user manual or call your software vendor for information on this feature 9 3 1 Online Claims for Residents of Residential Care Facilities Submit all claims for residents of residential ca
33. e approved amount Approval is valid for six months from the date on the approval letter or form If the date on the approval letter is more than six months before the date of service PharmaCare receives on the invoice an enquiry letter is sent requesting an explanation If the claim amount is higher than the PharmaCare approved amount an explanation of the difference is required as the health care provider should have resubmitted the application for pre approval of the new amount Billing over the pre approved amount for items that were not included in the original request or for changes made to the original request are not allowable expenses even if the change is for under 400 10 6 Health Care Provider s Role in Assisting Patients Submitting Manual Claims Health care providers may choose to have the patient pay the full amount of the device services and then make application to PharmaCare directly In this instance the health care provider must still apply for pre approval for all claims of 400 or more Fair PharmaCare patients may submit a claim for a prosthetic or orthotic device service directly to PharmaCare only if they have paid the entire cost to the health care provider Assist patients in making claims to PharmaCare by ensuring they have the correct information and documents and understand the process Health care providers should provide the patient with e a PharmaCare invoice e acopy of the health care provider invo
34. ection 6 below The health care provider site manager will be required to sign a BC PharmaCare Non Pharmaceutical Supplier Participation Agreement to be able to bill PharmaCare New health care providers will be provided with a start up package see Appendix 1 3 2 Prosthetic Health Care Providers Requirements 3 2 1 Breast Prostheses and Lymphedema Arm Sleeves Health care providers requesting to provide breast prostheses for mastectomy or lumpectomy patients through the PharmaCare program must be or must employ a certified fitter Health care providers requesting to provide lymphedema arm sleeves and gloves and or gauntlets for mastectomy patients must be or must employ a recognized provider who has vendor certification attesting to expertise in the field and who holds a certified fitter registration for lymphedema arm sleeves The majority of all work done fitting the patient must be provided by the certified fitters 3 2 2 Limb Prostheses Health care providers requesting to provide prosthetic benefits through the PharmaCare program must be or must employ Certified Prosthetists C P c or Certified Prosthetist Orthotist C P O c as certified by the Canadian Board for Certification of Prosthetists and Orthotists CBCPO The majority of the work related to the assessment fitting and dispensing of the prosthesis to the patient must be completed by the certified prosthetist 3 2 3 Ocular Prostheses Health care providers requ
35. egotiation The ADR process is intended to e encourage a co operative non adversarial climate e achieve flexible fair and appropriate settlements and e avoid the excessive financial psychological and procedural costs associated with formal court proceedings While it is believed that most audit disputes can and should be settled through the ADR process it is recognized that some cases will continue and be carried forward to a formal court proceeding The ADR process has a maximum 90 day time limit from the date of the first ADR meeting If all or some of the disputed issues are resolved the recovery amount including interest will be adjusted accordingly If a mutually acceptable recommendation is not arrived upon within 90 days the conclusions and recovery amount from the Final Audit Report will stand for the purposes of Page 35 of 47 repayment Repayments owing to PharmaCare as a result of the ADR process are subject to interest from the due date 11 2 9 Right of Recovery Section 37 of the Financial Administration Act requires the recovery and collection of overpayments made by government Further Section 38 of the Act Set off of amounts owed allows money to be recovered by set off A set off allows money to be deducted from any money owing by government If the health care provider fails to make the repayment required in the Final Audit Report and fails to reach an agreement via the ADR process the
36. eneees 35 11 2 9 Right Of RECOVENY sis savesadusa veins tev esecw ee idadievadedaisiaidvasavedesanciess 36 11 2 10 Confirmation Letter Program sccccceescsccccccceeeessccccceeeneees 36 Page 5 of 47 APPENDIX 1 PharmaCare Documents for Health Care Providers csecseees 38 APPENDIX 2 Reimbursement Schedule for Definitive Sockets ccceeeeeee 39 APPENDIX 3 Reimbursement Schedule for Prosthetic Procedures excluding Definitive SOCKEES caccxsanseasssins cvsandadawaevenaeaadunddaeneseaseusauesssucaneiaaanaanan 40 APPENDIX 4 Girling Formula siccssccascevecevasvecdessereedsseesuaasvecveasesecessacancavens 41 APPENDIX 5 Reimbursement Schedule for Orthoses cccecsssscccceessecees 42 APPENDIX 6 Reimbursement Schedule for Mastectomy Supplies eeeeee 47 Page 6 of 47 1 Introduction This Detailed Policy and Procedural Requirements manual provides health care providers with the information required to complete and submit claims to PharmaCare for all benefits under the Prosthetic and Orthotic Program It also provides information on the payment processes involved and on how to request assistance In this document the term health care provider refers to prosthetists orthotists ocularists anaplastologists mastectomy fitters and or their companies or businesses This manual is subject to the general policies outlined in the Prosthetic and Orthotic Program General Sta
37. equires another copy they can contact Information Support see to Section 2 5 for contact information Note For further information on completing this form refer to the PharmaCare PharmaNet Policies and Procedures Manual Section 6 1 1 Page 29 of 47 10 1 Payment for Manual Claims Manual claims submitted to PharmaCare where pre approval has been received will be reviewed and compared to the approval letter form Note For more detailed information on the payments refer to the PharmaCare PharmaNet Policies and Procedures Manual Section 6 For manual claims health care providers will receive a Remittance Advice Form from PharmaCare with each payment issued by the Ministry of Finance The Advice Form shows all claims processed by the site during the billing period PharmaCare processes manual claims on PharmaNet and pays its portion of each claim received determined by PharmaNet directly to the health care provider site Any balance should be obtained from the patient or his her private insurer Note If the approval letter or form for the claim is stale dated or if the claim amount is higher than the approved amount PharmaCare will postpone processing of the Fair PharmaCare Plan B Residential Care Plan C Income Assistance or Plan F At Home Program claim and send the health care provider an enquiry letter see Section 10 5 See Section 9 4 2 for information on claims for patients covered under Fair PharmaCare that res
38. esting to provide ocular prosthetic benefits through the PharmaCare program must be or must employ a National Examining Board of Ocularists Inc NEBO certified ocularist The majority of the work related to the assessment fitting and dispensing of the prosthesis to the patient must be completed by the certified ocularist Page 12 of 47 3 3 Orthoses Health care providers requesting to provide orthotic benefits through the PharmaCare program must be or must employ Certified Orthotists C O c or Certified Prosthetist Orthotist C P O c as certified by the Canadian Board for Certification of Prosthetists and Orthotists CBCPO The majority of the work related to the assessment fitting and dispensing of the orthosis to the patient must be completed by the certified orthotist 3 4 Out of Province Health Care Providers PharmaCare may allow out of province health care providers to participate in PharmaCare if they e serve British Columbia residents in border communities and e are closer than the nearest health care provider in British Columbia Occasionally special allowances will also be made for an out of province health care provider who can provide special services for a patient To participate in BC PharmaCare an out of province health care provider will be required to e make written application to the Manager Operational Services see Section 2 5 above and e sign and return a BC PharmaCare Non Pharmaceutic
39. ial considerations for their current health age or work requirements 7 2 2 Supporting Information for Prosthesis Replacement Physiological Change Simply stating Stump Atrophy or socket ill fitting is not a sufficient explanation for replacement For example you should also provide details about your patient including but not limited to the following e What ply socks is the patient wearing e Has padding been added to the prosthesis orthosis e Changes in stump measurements and e What adjustments have been done that may not have been sent in a previously approved application e g adjustments under 400 so pre approval was not required 7 2 3 Supporting Information for Prosthesis Replacement Wear and Tear Simply stating Worn out is not a sufficient reason for replacement Describe what is worn out and whether or not some parts can be replaced without replacing the full device For example include the following e Can the straps be replaced without making a new ankle foot orthosis e Does it have a hole in it If so where What caused it e ls there any delamination and e Has the plastic fractured If so is there something that can be changed for the next one to make it last longer Page 19 of 47 7 2 4 Supporting Information for a Partial Foot Prosthesis When filling out an application for a partial foot prosthesis provide a complete description of the item so that PharmaCare can more
40. iate PIN should be used on all applications and invoices Pricing approvals are based on the health care provider s usual and customary price up to the PharmaCare maximum reimbursement amount specified below For additional information about reimbursements for orthoses refer to Section 8 2 PIN Type of Orthosis Abbreviation Description Maximum Reimbursement 77123507 Supramalleolar Orthosis Child s brace SMO Must be made from high temperature plastic Must be custom fabricated from patient model Extends to just above malleoli ankle and to the toes Note that the following orthoses are NOT PharmaCare benefits o Foot orthoses o UCBL University of California Biomechanics Laboratory 800 77123508 Ankle foot orthosis rigid Child s brace AFO Must be made from high temperature plastic Must be custom fabricated from patient model Extends from below the knee down to and includes the foot Does NOT include an ankle joint but may be made from flexible plastic which will allow some movement 950 77123509 Ankle foot orthosis articulated Child s brace AFO Must be made from high temperature plastic Must be custom fabricated from patient model Extends from below the knee down to and includes the foot Include an ankle joint 1 150 77123510 Ankle foot orthosis with supramalleolar orthosis Child s brace AFO w SMO Must be ma
41. ice marked paid and e acopy of the PharmaCare approval letter or form Page 31 of 47 10 7 Patient s Deductible Not Yet Reached lf a Fair PharmaCare patient s annual deductible has not been met when the claims are processed some or all of the claim amount may accumulate towards the patient s deductible PharmaCare will send a zero payment letter to the health care provider when the PharmaCare portion is 0 00 for a Fair PharmaCare invoice see Section 9 4 2 Whether the patient has reached their deductable or not it is important to get pre approval for the claim and submit the claim to PharmaCare if it is a PharmaCare eligible claim 11 Audit 11 1 PharmaCare Audit PharmaCare Audit e performs health care provider audits and writes health care provider audit reports e makes recommendations to the PharmaCare Audit Review Committee concerning overpayment recoveries as a result of health care provider audits e makes policy and procedure recommendations to PharmaCare based on audit outcomes and e manages the Confirmation Letter Program The mandate of PharmaCare Audit is to provide reasonable assurance to the taxpayers of BC and the Ministry of Health that health care providers and individuals are adhering to proper claims practices as required by the Non pharmaceutical Suppliers Participation Agreement and PharmaCare policies and procedures Note For more information regarding PharmaCare Audit refer to the Ph
42. ir payments over the remainder or the year See Section 4 5 above 7 5 Denied Applications Notification if an application is denied will be provided including an explanation on why approval was not granted 7 6 Submissions that Exceed Basic Functionality Occasionally patients who are eligible for PharmaCare coverage may request components or devices that exceed basic functionality requirements Usually these patients have private insurance to cover the additional costs and require a denial letter from PharmaCare in order to access the funding from the private insurer In these circumstances submit two separate Application for Financial Assistance forms The first application includes all components that meet the basic functionality guidelines The second application includes the components that the patient will be supplied which exceed PharmaCare s basic functionality guidelines You will receive an approval letter or form for the application that meets the basic functionality needs of the patient and a denial letter for the application that exceeds the basic functionality requirements PharmaCare will only provide funding subject to your patient s usual PharmaCare plan rules and deductibles up to the approved value for the device that meets the basic functionality criteria Any future adjustments or repairs required on the device or components that exceed basic functionality will not be covered by PharmaCare 7 7 Switching Health C
43. irscirincsssrsiirisisvenisrorssrsevisrenit ier veis sieren i cidas okers 11 3 2 Prosthetic Health Care Providers RequireMents ceceeeecceeeeeeeeeeeees 12 3 2 1 Breast Prostheses and Lymphedema Arm Sleeves seeeeeeeee enone 12 3 2 2 AMB Prostheses So vicesievesecescicicvdauw seine EEE a eas 12 3 2 3 Ocular PROSENGSES isis cwcsee sy ceenuele neue bu ne re e e a 12 Dd OrtNOSES 55s Gaede kn dunn in Can Bsn ea dea e nea i ia hk ees 13 3 4 Out of Province Health Care Providers sssssssnssssseseseesssesseseesesssesee 13 PharmaCare Plans and Programs Available cccccccscscsccscccccsccccces 13 4 1 Fair PRAMMACENG oc racciee sentstesapncucsacorcxensacssates aieea EE EEE EEEE 14 4 2 Plan B For Permanent Residents of Licensed Residential Care Facilities 14 4 3 Plan C For People Receiving B C Income Assistance sssssssseseesess 14 4 4 Plan F For Children in the At Home Program ssssssssssesessesssesesseseeeese 15 4 5 Fair PharmaCare Monthly Deductible Payment Option ceeeee eee ee 15 Manager Operating Name Ownership Address Change ssssssccceceeeeees 16 Page 3 of 47 6 Connecting to PharmaNet eseesecsecsecsecsececsecseceesececoecesoecoeceececsecee 16 7 Application for Benefits sicinsscnwsnevadscinadsacmesanvacvededxeaniateveassasssnarcaeevecve 17 7 1 Application for Financial Assistance Process Pre Approval Mandatory 17 7 2 Co
44. love or Gauntlet 300 77123130 Lymphedema Arm Sleeve regular retail 77123128 Post Mastectomy Brassiere regular retail Page 47 of 47
45. mpletion of Applications for Financial Assistance ee esses ee eeeee 18 7 2 1 Supporting Documentation for New Amputee Prosthesis 66 19 8 7 2 2 Supporting Information for Prosthesis Replacement Physiological Change 19 7 2 3 Supporting Information for Prosthesis Replacement Wear and Tear 19 7 2 4 Supporting Information for a Partial Foot Prosthesis eeeeee 20 7 3 Review of Applications for Financial Assistance sceeee cence cece eeees 20 7A Approval Letter or ROM Moo tcsvacdendascaee rei eiea E NE KE 20 1 3 Denied Applications s sssrssssscsrsirrsssicsrescrrcrvsrssiesvesoercri riss iresoeicakr sssi 21 7 6 Submissions that Exceed Basic Functionality cc cece cece esse ce eeeeeeeeees 21 7 7 Switching Health Care Providers ssssssssenssssessssscesesesessecssesceseeeeeese 21 Te a E A E E E E ueassaue eaaaaes 22 Maximum Reimbursement Amounts ssssssssssoosesessessossssoosesessssoosese 23 8 1 For Prostheses sos usecavieieaaswasciayswanxiaedsarnneuseunmaiwasdtandudediouwapeeses 23 8 1 1 Definitive SOCKENS 2 42 455000954 3003 oancpeoeweee sade nnsa E EEE AEE ETER a 23 8 1 2 Other Prosthetic Procedures sesessessosesscseosessssossesescosonessosee 23 8 1 3 Component pricing sesesesesesesesesesosesesesesososesososesosesesoseses 24 8 1 4 Exchange Rate on Components Purchased Outside Canada 24 8 1 5 Prosthetic Adjustments
46. n PharmaCare may deduct the amount of the overpayment from any money owing to the health care provider 11 2 10 Confirmation Letter Program The Confirmation Letter Program confirms information about prosthetic and orthotic claims Two types of confirmation letters are sent as described below Random Patient Letters The Confirmation Letter Program randomly confirms information with patients concerning PharmaCare paid claims Each month approximately one health care provider is randomly sampled A random sample of patients from that health care provider are mailed a confirmation letter Approximately 100 letters in total are mailed to patients requesting confirmation of designated medical devices and or services received in the previous two months Patients sometimes misinterpret the intention of the confirmation letter Health care providers should reassure the patient that the Confirmation Letter is not issued to question the patient s claim but rather to confirm that the patient did indeed receive the medical device that was paid for by PharmaCare on their behalf Each letter is mailed with a self addressed pre stamped envelope If the first letter is not returned within six weeks a second request is mailed Health care providers should encourage patients to return the letters to PharmaCare Audit using the envelope provided Note Phone numbers for the public are included in the letter for any person wishing to contact PharmaCa
47. nal information that is relevant or which might have been overlooked during the audit it should be included in the health care provider s response This response will be considered and all or part of it may be incorporated into the Final Audit Report approved and issued by PARC Note There is a 30 day limit to the Draft Audit Report feedback process 11 2 7 Final Audit Report The Final Audit Report will contain the decision of PARC The audit may be concluded with no further action or with a required recovery of funds In the event of a recovery of funds the covering letter of the Final Audit Report will outline the repayment options As per the Ministry s Financial Administration Policy the date of the Final Audit Report covering letter is the due date for the calculations and repayment purposes When the recovery amount is 30 days overdue it will be subject to interest as per the Financial Administration Act Section 20 and the Interest on Overdue Accounts Receivable Regulation Results of audits may be referred to regulatory bodies as applicable and if appropriate 11 2 8 Alternative Dispute Resolution In the event of a dispute an Alternative Dispute Resolution ADR meeting date may be requested in writing by the health care provider manager owner in response to the Final Audit Report The ADR process provides health care providers with several options for settling disputes ranging from informal problem solving to structured n
48. nsure their Plan information is still correct Note For information on PharmaCare Plans see Section 4 above or refer to the PharmaCare PharmaNet Policies and Procedures Manual under Chapter 8 7 2 Completion of Applications for Financial Assistance All Applications for Financial Assistance forms should be fully completed and include a full description of the need for the device why they need it For example the rationale should include a full description of why you are requesting a new or replacement prosthesis for the patient or why you feel that the patient requires an articulated Ankle Foot Orthosis AFO rather than a rigid one Information from all sources should be documented to justify your decision including information regarding e The patient s current needs and abilities e Gait analysis e Ability to use the device e Occupational requirements e Functional ability and e Whether this is their dominant hand etc Information located on the form already should not be stated as a reason for requiring the device For example information that should not be included as it is already on the form includes e Stating age birth date is already on the form if the form is complete e Stating diagnosis already on the form if the form is complete or e Level of amputation already on the form if the form is complete A description of the prosthesis orthosis and or service is required on the Application for Financial
49. ose of business US Exchange rate published by the Bank of Canada www bank banque canada ca en rates exchange look html In times of significant fluctuation the rate is adjusted whenever it changes more than five cents and remains at a variance of five cents or more for a minimum of five working days When the US Exchange rate changes the new rate is posted in the next PharmaCare Newsletter 8 1 5 Prosthetic Adjustments and Repairs Claims for repairs and adjustments should be considered when e the cost of the repair adjustment is substantially less than the cost of the replacement e the repair or adjustment extends the useful life of the device or e the device is under the three year replacement period No claims for repairs or adjustments should be made to PharmaCare when e the products are under a manufacturer s or health care provider s warranty e the device or component does not meet PharmaCare s basic functionality criteria or e the device was purchased by a patient their private insurance another insurer such as ICBC WorkSafeBC Veterans Affairs Canada Health Canada s Non Insured Health Benefits Program similar programs from other provinces or jurisdictions or under an award for damages Adjustments and repair costs include e labour Page 24 of 47 e cost of components required for the health care provider to complete the repair plus the Girling Formula and e the actual cost of the manufacturer
50. plete and the device has been dispensed to the patient 9 2 Financial Control in PharmaNet PharmaNet includes a financial control that limits processing of claims of 400 or more to the six month window of the pre approval time limit As each Application for Financial Assistance is approved a financial control is entered into PharmaNet to allow for the processing of the claim over the next six months If you receive the following message Patient Not Entitled when you process a claim you should check the claim to ensure e That you have received an approved Application for Financial Assistance for the claim that you are processing e That you are processing the claim under the appropriate PIN for the correct Personal Health Number PHN and under the correct pharmacy equivalency code PEC and e That you are processing the claim within six months from the approval date If you have confirmed the above information is correct and you still cannot complete the claim then contact the Prosthetic and Orthotic Clerk at HIBC for assistance see Section 2 4 above Page 26 of 47 9 3 Online Claims Online claims are accepted for prostheses and prosthetic services under Fair PharmaCare Plan B Residential Care Plan C Income Assistance and Plan F At Home Program Online claims are accepted for orthoses and orthotic services under Fair PharmaCare Plan C Income Assistance and Plan F At Home Program Software ven
51. quirements until at least the end of PharmaCare s established time limits for the replacement of the product or device see Section 5 Prosthetic and Orthotic Program General Statement of Program Policy 7 4 Approval Letter or Form When an application is approved health care providers receive an approval letter or form from PharmaCare detailing e the patients name e the products services approved and fora Plan B Residential Care Plan C B C Income Assistance or Plan F At Home Program patient the total dollar amount approved or Page 20 of 47 for Fair PharmaCare patients an approved amount subject to determination of the patient s deductible For Fair PharmaCare patients PharmaCare cannot determine in advance the portion of the claim it will pay because this amount will depend on the patient s deductible at the time the claim is processed so the approval is based on the maximum amount that would be approved by PharmaCare The actual payment amount is the maximum approved amount less the patient s deductible and co pay at the time the claim is processed Fair PharmaCare patients who have not registered will have a deductible of 10 000 and the costs accumulate towards their deductible but they will not be eligible for any retroactive reimbursements see Section 2 2 Patients may choose to register for the Monthly Deductible Payment Option to assist them by spreading the deductible portion of the
52. r period of required record retention is due to expire the health care provider must retain those records and any supporting documentation until such time as the health care provider is advised in writing by the Ministry of Health that the audit is concluded All original documentation must be kept for a minimum three years Premature destruction incomplete records missing not found or damaged records as a result of inadequate filing systems will not be accepted as a reason for incomplete documentation Unsubstantiated claims are subject to recovery by the Ministry of Health as a PharmaCare overpayment Patient records should include supporting documentation for all claims PharmaCare may deduct the amount of the overpayment from any money owing to the health care provider Please note that patient files should include supporting documentation for all claims regardless of the amount paid by PharmaCare this includes claims under 400 11 2 5 Audit Scope All claims manual or online paid in whole or in part by PharmaCare are subject to audit by duly authorized government representatives of the PharmaCare program PharmaCare Auditors will require access to those claims All PharmaCare policies and procedures may be the subject of a health care provider audit Health care providers must abide by all requirements of any professional College licensing or certification boards such as the Canadian Board for Certification of Prosthetists and Or
53. re Audit Page 36 of 47 Select Verification Letters As part of a health care provider audit letters may be mailed to physicians or patients to verify information Help Desk phone numbers for enquiries are provided on each verification letter and a self addressed pre stamped envelope is included Physician verification letters also contain the lead auditor s name and direct telephone number Second request letters are mailed six weeks after the first mailing Page 37 of 47 APPENDIX 1 PharmaCare Documents for Health Care Providers PharmaCare provides each new health care provider with a start up information package that includes Non Pharmaceutical Supplier Participation Agreement Fair PharmaCare brochures and Registration Information Slips Direct Deposit Application form List of Prosthetic Orthotic PINs 4 pages Form 5400 Orthotic Benefits Application for Financial Assistance Instructions for Form 5400 Form 5401 Orthotic Benefits Invoice Instructions for Form 5401 Form 5402 Prosthetic Benefits Application for Financial Assistance Instructions for Form 5402 Form 5403 Prosthetic Benefits Invoice Instructions for Form 5403 Form 5404 Prosthetic Benefits Non Limb Application for Financial Assistance Instructions for Form 5404 You may request additional copies of these documents by telephoning the HIBC PharmaNet Help Desk see Section 2 3 1 for contact numbers APPEN
54. re facilities under Plan B e Claims of 400 or more the Plan B claim number also known as the facility number is provided in the PharmaCare approval e Claims of less than 400 the PharmaNet Help Desk will provide you with a Plan B claim number when you call to arrange for submission of the claims e Submit online Plan B claims with the facility s Plan B claim number in the Group ID field Contact the PharmaNet Help Desk to make arrangements to submit online claims on the following day see contact details in Section 2 3 1 Page 27 of 47 9 4 Manual Claims Manual claims are accepted for prostheses and prosthetic services under Fair PharmaCare Plan B Residential Care Plan C Income Assistance and Plan F At Home Program Manual claims are accepted for orthoses and orthotic services under Fair PharmaCare Plan C Income Assistance and Plan F At Home Program Manual claims of 400 or more must be accompanied by a copy of the PharmaCare approval letter or form Patients are responsible for payments if their Fair PharmaCare deductible has not been met For claims less than 400 PharmaCare pre approval is not required Health care providers may prefer that their patient pays in full and submits a manual claim directly to PharmaCare rather than submitting on the patient s behalf This minimizes the possibility that the health care provider will receive a zero payment letter see Section 9 4 2 below from PharmaCare
55. t be custom fabricated to patient or patient model e Needed to provide spinal stability for patients with spina bifida scoliosis Cerebral Palsy or other neuromuscular conditions and similar medical conditions e All requests for Cheneau style braces must include appropriate documentation showing that the team responsible for the patient has taken the Cheneau training Ata minimum the team must include an orthotist and a physiotherapist e Note that the following orthoses are NOT PharmaCare benefits o Cervical collars alone o Cervicothoracic Orthosis i e SOMI Sternal Occipital Mandibular Immobilizer Minerva Brace Aspen Brace Halo Devices Spinal Orthosis required post surgery o Spinal Orthosis to treat spinal fractures o SpineCor Brace 0000 LSO e LSO is the acronym for Lumbar Sacral Orthosis 1 835 Page 45 of 47 PIN Type of Orthosis Abbreviation Description Maximum Reimbursement TLSO e TLSO is the acronym for Thoracic Lumbar Sacral Orthosis e Acustom molded plastic body jacket or thoracolumbosacroal orthosis TLSO is fabricated from polypropylene or plastic This orthosis is frequently a two piece plastic clamshell design it may be a single piece that opens in the front or rear that extends from the pelvis to just below the collar bones e May include a feeding tube in the design e All requests for Cheneau style braces must include appropria
56. te documentation showing that the team responsible for the patient has taken the Cheneau training At a minimum the team must include an orthotist and a physiotherapist e This would include the following types of braces o Boston Brace Hybrid TLSO Bi valved TLSO Clamshell TLSO Milwaukee Brace Charleston Bending Brace Cheneau style Brace 000000 2 010 CTLSO e CTLSO is the acronym for Cervical Thoracic Lumbar Sacral Orthosis e This would include the following types of orthosis o Milwaukee Brace 2 210 77123499 Plagiocephaly orthosis Child s helmet 2 850 77123504 Orthotic repairs and adjustments Use ONLY if pre approval NOT required This PIN should ONLY be used for eligible PharmaCare claims under 400 that do not require pre approval 400 77123528 Orthotic repairs and adjustments Use if pre approval required by approval Page 46 of 47 APPENDIX 6 Reimbursement Schedule for Mastectomy Supplies Reimbursement for mastectomy products are based on the type of product being supplied The appropriate PIN should be used on all applications and invoices PIN Description Maximum Reimbursement 77123116 Breast Prosthesis Left 350 77123104 Breast Prosthesis Right 350 77123117 Lumpectomy Left 300 77123118 Lumpectomy Right 300 77123533 Off Shelf Glove or Gauntlet 150 77123534 Custom G
57. tement of Program Policy and to general PharmaCare policies as outlined in the PharmaCare PharmaNet Policies and Procedures Manual Health care providers must abide by the PharmaCare policies and procedures outlined in the policy manuals and those provided in PharmaCare Newsletters PharmaNet Bulletins and other program directives as issued from time to time Note For further information on PharmaCare Newsletters and PharmaNet Bulletins refer to Section 1 1 below and to the PharmaCare PharmaNet Policies and Procedures Manual Section 1 1 3 1 1 How are policies and procedures updated Updates of policies and procedures are communicated in PharmaCare Newsletters PharmaNet Bulletins PharmaCare PharmaNet Policies and Procedures Manual or other directives as provided from time to time PharmaCare Newsletters are initiated by PharmaCare to e announce changes in PharmaCare policies and procedures e clarify existing policies e announce changes in benefit status for specific Drug Identification Numbers DINs and Product Information Numbers PINs including delistings and restrictions and e announce new benefits PharmaCare Newsletters are produced in a consistent format numbered consecutively by year and dated PharmaNet Bulletins are initiated by PharmaCare and the College of Pharmacists to e announce PharmaNet related changes and e educate pharmacy or health care provider staff regarding PharmaNet related issues PharmaNet
58. thotists the Pharmacy Operations and Drug Scheduling Act if connected to PharmaNet and any other federal and provincial requirements PharmaCare payments resulting from failure to do so are subject to recovery by the Ministry of Health and may be reported to the appropriate regulatory authority Audit staff will review patient files to verity e the original prescription from the physician authorizing the prosthesis or orthosis except for mastectomy prostheses and supplies e all original hand written notes in the patient file identifying what occurred on each visit and what was dispensed to the patient and e original copies of the Application for Financial Assistance forms approval letters forms and invoices with the original patient signatures Audits include the review of patient files to verify that amounts have been paid for valid claims and that the authorizing practitioner s dispensing instructions were followed Note In situations where criminal conduct is suspected cases will be forwarded to the RCMP for investigation 11 2 6 Draft Audit Report A Draft Audit Report is mailed to the health care provider for response The health care provider is given an opportunity to produce any documentation not previously found Page 34 of 47 It is very important for the health care provider to carefully review the Draft Audit Report and identify any errors in fact or in the report s conclusions Also if there is additio
59. tic or similar extension ONLY KAFO e Should include metal sidebars 2 040 for full e Must be custom fabricated from KAFO patient model e Extends from above the knee to below knee where it can attach to an AFO e Includes a knee joint but NOT an ankle joint e Please specify if this is just a knee extension orthosis to be used with an AFO and does not include the cost of the full AFO 77123514 Knee ankle foot orthosis e Shells must be made from high 2 240 articulated ankle Child s temperature plastic or similar brace KAFO e Should include metal sidebars e Must be custom fabricated from patient model e Extends from above the knee to below knee where it can attach to an AFO e Includes the cost for ankle joint plus a knee joint and the additional time requirements 77123515 Hip knee ankle foot e Must be made from high 4 000 orthosis Child s brace temperature plastic or similar e Must be custom fabricated from patient model e Extends from hip down where it can attach to a KAFO e Includes the cost for ankle joint a knee joint plus a hip joint and the additional time requirements Page 44 of 47 PIN Type of Orthosis Abbreviation Description Maximum Reimbursement 77123516 Reciprocating gait orthosis Child s brace MUST result from a Team Assessment with appropriate Team support by approval 77123517 Spinal orthosis Child s brace e Mus
60. ult in a zero payment letter 10 2 Payment for Online Claims For online claims a Remittance Advice Form is issued only for adjustments to previous claims To access other payment data use your PharmaNet compliant software s feature for retrieving daily totals described in Section 9 3 10 3 Claims Rejected by PharmaCare If PharmaCare rejects any of your claims the claim form is returned to you Claims accepted by PharmaCare are not returned 10 4 Incomplete or Incorrect Claims PharmaCare returns all incomplete or incorrect invoice claim forms to the health care provider for correction or completion If an incomplete or incorrect invoice is returned to you 1 Correct or complete the original invoice Do not submit a new invoice 2 Ensure that the date on the invoice is the date the product or service was received by the patient 3 Re submit the invoice Note The invoice is also returned if the claim is rejected due to patient ineligibility If the patient is ineligible the invoice should not be re submitted Page 30 of 47 10 5 PharmaCare Enquiry Letters PharmaCare will postpone the processing of your manual Fair PharmaCare Plan B Residential Care Plan C Income Assistance or Plan F At Home Program invoice and will send an enquiry letter to you in the following situations e the approval letter or claim is stale dated e the invoice requires further clarification or e the amount is higher than th
61. uring fabrication of definitive socket 205 Strap Patellar Tendon Bearing PTB 170 Suction Procedure TF only 300 Test socket diagnostic dynamic trans femoral TF 600 Test socket diagnostic dynamic trans tibial TT 500 Test socket diagnostic static trans femoral TF 450 Test socket diagnostic static trans tibial TT 350 Test socket diagnostic static trans radial TR 350 Test socket diagnostic static trans humeral TH 350 Note Many of the maximum reimbursement amounts listed above may include the cost of some small components and the labour required to complete the procedure Page 40 of 47 APPENDIX 4 Girling Formula Percentage Increment Chart Catalogue Markup Markup Costed Imported item Imported item price in Can Amount out at mark up costed out at Up to 500 100 500 1 000 120 1 100 501 600 95 595 1 195 95 1 295 601 700 85 680 1 380 85 1 480 701 800 75 755 1 555 75 1 655 801 900 65 820 1 720 65 1 820 901 1 000 55 875 1 875 55 1 975 1 001 1 100 45 920 2 020 45 2 120 1 101 1 200 35 955 2 155 35 2 255 1 201 1 300 25 980 2 280 25 2 280 1 301 1 400 25 1 005 2 405 25 2 505 1 401 1 500 25 1 030 2 530 25 2 630 1 501 1 600 25 1 055 2 655 25 2 755 1 601 1 700 25 1 080 2 780 25 2
62. vided on the College of Pharmacists of British Columbia s website at www bcpharmacists org library E Registration Licensure E 3 Pharmacy 5033 Guide CommunityPcyLicensure AppA pdf Note The compliance evaluation process is performed by PharmaCare s Quality Assurance staff plus a member of the Ministry of Health and a member of a regulatory body where appropriate The evaluation confirms that the local software complies with all requirements and that all local system functions and processes provide accurate results The compliance evaluation process evaluates all aspects of PharmaNet functionality available on the local software regardless of whether or not the functionality is used by the pharmacy health care provider 7 Application for Benefits Apply for PharmaCare benefits on behalf of your patients by submitting one of the following forms to PharmaCare e PharmaCare Prosthetic Benefits Application for Financial Assistance e PharmaCare Orthotic Benefits Application for Financial Assistance e PharmaCare Prosthetic Benefits Non Limb Application for Financial Assistance Forms and instructions on how to complete them are available online from the PharmaCare website at www health gov bc ca pharmacare suppliers html Pre approval is required for all benefits valued at 400 or more In the absence of pre approval PharmaCare will not pay for benefits provided to patients Approvals are valid for six 6 months following the approval

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