4.1 Claims by Offline and Out-of-Province Providers
Last updated on March 13, 2024[July 31, 2019: Updated for clarifications]
General Policy Description
This section provides information for providers who are not connected to PharmaNet, but who participate in PharmaCare.
Policy Details
Connection to PharmaNet for in-province providers (other than pharmacies) is not mandatory.
Out-of-province (OOP) providers must enroll in the PharmaCare program as providers if they wish to participate in PharmaCare, that is, be paid by PharmaCare or enable their patients to be reimbursed by PharmaCare.
Offline and OOP providers should note that an individual ceases to qualify for PharmaCare coverage on the day they leave British Columbia to reside elsewhere, even though Medical Services Plan (MSP) coverage may continue.
Offline and OOP providers may submit manual claims to PharmaCare for benefits being provided to B.C. residents with PharmaCare coverage for the drug or device in question through 100% coverage plans (Plans C, D, F, G, W and Z).
Offline and OOP providers should not submit manual claims to PharmaCare for benefits provided to B.C. residents with coverage under only Fair PharmaCare (Plan I). Fair PharmaCare beneficiaries may submit claims using the Manual Patient Claims process detailed in Section 4.2—Manual Patient Claims.
Offline and OOP providers may opt out of PharmaCare at any time, but if they do so their patients will not be reimbursed by PharmaCare for any purchases made at their site.
OOP sites wishing to be providers are required to sign a declaration.1 If the enrolment application is approved, the site will become a PharmaCare provider, but will not be connected to PharmaNet.
OOP providers are subject to the same policies and procedures as in-province providers.
Payment is not made for B.C. residents visiting an OOP community. Payment is provided only because the OOP provider is closer to or more accessible from a B.C. resident’s home than the nearest B.C. provider.
All claims by providers are subject to PharmaCare Audit.
1By signing the declaration, OOP providers agree to serve the residents of B.C., to be bound by the laws of the Province of B.C. and to have any court proceedings related to their enrolment in PharmaCare conducted in B.C.
Procedures
Processing manual claims
Upon receipt of a manual claim, PharmaCare adjudicates the claim using the PharmaNet system.
If a manual claim is accepted, payment for the PharmaCare portion is issued by the Ministry of Finance and a statement (the "Remittance Advice") is sent by PharmaCare to the provider. The Remittance Advice itemizes all processed claims for an individual provider.
The documentation submitted with an accepted claim is not returned.
Claims that are not accepted—as well as those that are incomplete or incorrect—are returned to the provider with the Remittance Advice.
For more information on rejected claims, please refer to Incomplete/Incorrect Claims below.
Direct deposit payments
The Ministry of Finance issues payments to providers for accepted claims. To receive payment by electronic funds transfer, complete a British Columbia Government Direct Deposit Application. Submit the application and an original void cheque to:
PharmaCare Information Support
PO Box 9655 Stn Prov Govt
Victoria BC V8W 9P2
The Direct Deposit Application is included in the PharmaCare Welcome Package sent to new providers, and additional copies are available from Health Insurance BC (HIBC) Info Support at informationsupport@hibc.gov.bc.ca.
All manual provider claims must include
- The top copy of the completed PharmaCare Claim Forms (HLTH 5336)
- A PharmaCare Claim Form is a record of the information for each individual product dispensed.
- The provider's work order/invoice, with costs itemized
- The top copy of a completed PharmaCare Prescription Invoice (HLTH 5335)
- A PharmaCare Prescription Invoice contains a summary of the total number and total dollar value of the claims submitted. Up to 100 claim forms may be submitted with a single Prescription Invoice.
Completing the three-part PharmaCare Claim Form (HLTH 5336)
Ensure that all the following information is provided and that the correct unit of measure is used when specifying product quantity.
1. Complete a separate PharmaCare Claim Form for each product or service (even if a number of products or services are provided for the same patient), including all the following information:
| Patient | Patient's name and Personal Health Number (PHN) |
|---|---|
| Date | Date (YYY/MM/DD) that the device or service was provided |
| Pharmacy | Name of the provider to whom payment should be sent |
| Pharmacy Code | Provider's Site ID |
| Plan | PharmaCare Plan (Plan C, D, F, G, W, or Z) |
| Physician MSP Number | Prescribing physician's MSP billing number |
| Prescription No. | Provider's work order or invoice number |
| Quantity | The full metric quantity of the drug or product covered by the claim. See Correct Quantities. |
| CDIC No. |
The federal government's DIN (Drug Identification Number) for drugs or the PharmaCare-assigned PIN (Product Identification Number) for compounds or products Refer to the lists of Product Identification Numbers available at Information for Pharmacies and Information for Device Providers. |
| Dispensing Fee | Up to the PharmaCare maximum |
| Ingredient Cost |
Up to the maximum cost covered by PharmaCare See Sections 5.6—5.22. |
| Total $ Claimed | Total of Dispensing Fee and Ingredient Cost |
| Balance Due | Grand total (same amount as in the Total $ Claimed) |
| Signature of Patient (or Agent) | Patient/Agent's signature (An agent may be the parent of a child patient or someone with Power of Attorney for a patient.) |
2. Submit the top copy of each PharmaCare Claim Form to PharmaCare with supporting documents such as work orders or invoices. (Up to 100 Claim Forms can be sent in with each Prescription Invoice.) Give the second copy to the patient. Retain the third copy for your records.
1. Complete the invoice, including all of the following information:
| Pharmacy Identification | Provider's name and address |
|---|---|
| Date | The date of the invoice (YYYY/MM/DD) |
| No. of Claims Submitted | Total number of claims being submitted with this invoice |
| Phcy. Code | Provider's Site ID |
| Total Amount Invoiced | Total $ amount for all the claims covered by this invoice |
| Signature | Provider's authorized representative's signature |
| Position | Position or title of the person who has signed the invoice |
2. Submit the top copy of the Prescription Invoice with the top copy of up to 100 claim forms and associated documents by mail to:
PharmaCare
PO Box 9655 Stn Prov Govt
Victoria BC V8W 9P2
Retain the second copy of the invoice (labelled PHARMACY) for your records.
Note: Forms may be couriered to:
PharmaCare
Health Insurance BC
716 Yates Street
Victoria BC V8W 1L4
Quantities
Accurate quantity reporting is critical to the efficient and accurate adjudication of claims.
If you are unsure of the unit of measure to use for a particular product, consult the Correct Quantities list on the PharmaCare website.
PharmaCare returns incomplete or incorrect claim forms to the provider for correction or completion. The claims are returned with the Remittance Advice. The Prescription Invoice that accompanied the claim will not be returned; PharmaCare retains the invoice and deducts the amount of the incomplete or incorrect claim from the invoice total.
The claim form is also returned if the claim is rejected due to patient ineligibility or because the product is not a benefit. These claims should not be re-submitted.
If an incomplete or incorrect claim form is returned to you:
- Correct or complete the original form. Do not submit a new claim form.
- Ensure that the date on the claim form is the date the product or service was received by the patient.
- Include the $ amount of the corrected claim on a new PharmaCare Prescription Invoice.
- Submit the Claim Form and Prescription Invoice to HIBC.