2.1 PharmaCare Provider Enrolment

[August 2019: Updated to reflect change in provider subclass to opioid agonist treatment provider]

General Policy Description

The Provider Regulation ("The Regulation") under the Pharmaceutical Services Act ("the Act") came into force on December 1, 2014. The Regulation sets out enrolment criteria for pharmacists, facilities, and other places where drugs, devices, substances or related services are provided ("sites").

To submit PharmaCare claims for their patients and to be eligible for any PharmaCare payments, a site (pharmacy or device provider) must apply for enrolment in the PharmaCare program.

Policy Details

PharmaCare makes payments on behalf of beneficiaries for eligible drugs, medical supplies and services, only to providers who

 
Beneficiary A person enrolled in a PharmaCare drug plan
Benefit A drug, device, substance or related service listed on a formulary or Related Services List
Claim A claim for payment that is submitted by a provider to PharmaCare in respect of a benefit provided to a beneficiary
Provider A site (e.g., pharmacy, device provider) that is enrolled in PharmaCare for the purpose of receiving payment
Manager
Class

The two classes of provider established in the Provider Regulation:

  1. pharmacy provider
  2. device provider
Sub-class

Sub-classes within each class, which includes

  • For the pharmacy provider class: Plan B and Opioid Agonist Treatment (OAT) provider
  • For the device provider class: compression garment provider, limb prosthesis provider, breast prosthesis provider, ocular prosthesis provider and orthosis provider; and other (ostomy supplier, diabetes supplier)

A Provider Enrolment Form (HLTH 5432)(PDF, 585KB) should be completed by any site wishing to enrol as a provider with PharmaCare in order for

  • The site to receive payment for providing PharmaCare benefits to eligible individuals, or
  • Individuals eligible to receive payment for PharmaCare benefits provided by their site.

A separate Provider Enrolment Form must be submitted for each site.

 

  • Anyone who needs PharmaNet access only to view patient records (e.g., medical practitioners, emergency departments)
  • Inpatient-only hospital pharmacies
  • Allergists and allergy laboratories
  • Fertility clinics
  • Dispensing physicians—unless the College of Physicians and Surgeons of British Columbia identifies the medical practitioner as a person who should be receiving payment for claims and it would be in the public interest for the medical practitioner to receive payment for claims

The Act, the Regulation, and the College of Pharmacists of British Columbia bylaws establishes the following obligations for providers:

  • The provider must have a designated pharmacy manager, and a valid and subsisting pharmacy licence for the pharmacy at all times. 
  • All claims submitted to PharmaCare must be submitted in accordance with the provisions of applicable law and College of Pharmacists of BC rules.
  • All claims submitted to PharmaCare must contain all information required by PharmaCare.
  • All claims submitted to PharmaCare must be true, accurate and complete to the best of the provider’s knowledge.

The provider shall not submit a claim to PharmaCare that the provider knows or reasonably ought to know is false, inaccurate or misleading.

Except where the pharmacy provider is expressly directed or permitted by PharmaCare to submit claims in another manner, the provider must use PharmaNet to submit all claims. The provider shall abide by conditions established by PharmaCare in respect of connection to and use of PharmaNet, including, but not limited to, PharmaNet Professional and Software Conformance Standards.

Providers cannot claim an amount for a benefit that exceeds what the provider would charge to any other person. 

>> For further details, see Section 17 of the Provider Regulation.

The provider shall abide by all PharmaCare policies and procedures, provided that they are given reasonable notice of new or revised policies and procedures in advance of implementation through PharmaCare Newsletters or PharmaNet Bulletins.

In accordance with the College of Pharmacists of BC’s bylaws, no inducements shall be offered by the provider, or by an agent on behalf of the provider, to any other person to secure prescription orders, or in relation to the provision of a drug, medical supply, or service on the portion of the cost reimbursed by PharmaCare.

“Inducement” means incentives including, but not limited to, cash, points, loyalty points, coupons, discounts, goods, rewards and similar schemes which can be redeemed for a gift or other benefit.

>> Refer to the Pharmaceutical Services Act, Part 5, Section 51(2).

Refer to Section 10 - Audit for details.

Subject to 30 days' notice and an opportunity to be heard, the Minister may

  • Change or cancel a designation made under the Act, or
  • Cancel a provider's enrolment.

The Minister must give a provider notice of the following:

  • An intention to change or cancel a provider's enrolment in a class or sub-class
  • An intention to change or add limits and conditions on a provider's enrolment

A provider who receives a notice described above may respond within the period set out in the notice. The response should be in the form of a written submission respecting why the Minister should accept the applicant's application for enrolment, should not change or cancel the provider's enrolment, or should resume payments to the provider, as applicable, and any relevant records or other evidence to support the position of the applicant or provider.

  • On receipt of a response from the provider, the Minister must consider the submission, records and evidence provided; may vary, confirm or reverse the decision to deny the applicant's enrolment, change or cancel the provider's enrolment, or take any action the Minister must or may take under the Act, as applicable, and; must give notice to the applicant or provider of the decision or action taken.

A notice given by the Minister under the Act is deemed to have been received

  • If sent by registered mail or any other form of delivery, other than personally or electronically, three days after the date the notice was sent;
  • If sent electronically, 24 hours after the time the notice was sent.

The Minister, without giving notice or an opportunity to be heard, may suspend payments owing under Section 45 of the Act by the government to a provider if

  • The provider has engaged in conduct that could be the subject of enforcement action, or has been convicted of a prescribed offence (see below) under an enactment of B.C. or Canada, 
  • Prescribed circumstances exist (see below), or
  • It would be in the public interest to suspend payment.

As soon as reasonably practicable after suspending payments, the Minister must give notice of the suspension and an opportunity to be heard.

The Minister must resume payments and pay any amounts owing during the suspension period if the Minister suspends payments

  • On the grounds set out in an enforcement action that is not commenced within three months of the suspension, or
  • Following a hearing, the Minister determines that 
    • the grounds for suspending the payments no longer exist, or
    • suspension of payments is unnecessary for any reason or is not required to protect the public interest.

If a provider does not respond within 21 days after notice is given or if the Minister does not resume payments after giving an opportunity to be heard

  • The Minister, if applicable, may cancel the enrolment of the provider without giving further notice or an opportunity to be heard, and
  • Despite any provision of the Act, or a regulation or an agreement made under it, no further amounts are owing to the provider, and any agreement with the provider is terminated without notice or compensation of any kind.

The prescribed offences for suspension of payments are as follows:

  • Sections 362, 366, 380, 388, 389, 392, 397, 402, 402.2, 403 and 408 [fraud] of the Criminal Code
  • Section 5 [trafficking] of the Controlled Drugs and Substances Act (Canada)
  • Section 46 of the Controlled Drugs and Substances Act (Canada), as it relates to a contravention of any provision of said Act
  • Part 2 [permitted activities and general obligations of pharmacists] of the Benzodiazepines and Other Targeted Substances Regulations (Canada), SOR/2000-217, or
  • Sections 30 to 45 of the Narcotic Control Regulations (Canada), C.R.C., c. 1041

The prescribed circumstances for suspension of payments are as follows:

  • If the provider is a corporation and an officer or a director of the provider has been convicted of an offence referred to above
  • If a provider becomes ineligible to be enrolled as a provider, except in the circumstances relating to an outstanding audit amount
  • In the case of the Opioid Agonist Treatment Provider sub-class: if the pharmacy provider's site is no longer served by pharmacists who are appropriately qualified to dispense medications for opioid agonist treatment (OAT)
  • In the case of a device provider sub-class: if the device provider's site is no longer served by a person who is appropriately qualified as described by that section to provide the applicable type of benefit

Once you have submitted your application, you are required, as owner of the site, to notify Health Insurance BC (HIBC) of any of the following in accordance with the notification requirement specified in the table below.

Failure to abide by your duties and obligations may result in the delay or suspension of payments.

 
Change Notification Requirement
Change in provider contact information Minimum 7 days before change
Change of operating/business or corporate name Minimum 7 days before change
Change in owner information Minimum 7 days before change
Change of manager Minimum 7 days before change
Change of location Minimum 7 days before change
Changes to a Power of Attorney Minimum 7 days before change
Cancellation of sub-class

Opioid agonist treatment—30 days before services will end

Plan B—No later than the last day of the month before the final full month in which service will be provided

Device Provider—As soon as reasonably practicable
Request to add a sub-class Recommended notification period: Submit the request at least 21 days in advance of requested effective date to allow for processing. 
Notice of certain action or event(s)* Immediately
Notice of disposition (sale) or closure Minimum 30 days before change

*Actions or events include: order, suspension and/or cancellation of billing privileges, judgment or conviction; suspension or cancellation of pharmacist’s registration and/or pharmacy licence; disciplinary action taken by a governing body or action or proceeding taken by the Canadian Board for Certification of Prosthetists and Orthotists; instances in which an owner of the site has been the director of a corporation that has declared or been petitioned into bankruptcy; and, a requirement to pay an amount to a public insurer, other than BC PharmaCare.

>> Refer to Changing your enrolment information for instructions on how to submit a notice of changes to your enrolment information.

 

Procedures for Enrolling as a PharmaCare Provider

For information on the PharmaCare enrolment process and requirements, see the PharmaCare Provider Enrolment Guide.

The following enrolment forms are available at Forms for Pharmacies or Information for Device Providers:

Approved sites become PharmaCare providers and are issued a Site ID (e.g., A01)—a unique identification code issued by HIBC and formerly known as the “Pharmacy/PharmaCare Code/ID.”

Notify PharmaCare Information Support at HIBC of changes to your enrolment information using the PharmaCare Provider Change Form (HLTH 5433) (PDF, 746 KB).

>> For information of notification requirements regarding changes to PharmaNet connections, see Section 2.5.

>> For contact information, see Section 11.

 

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