Health

Government of New Brunswick

NB Drug Plans Claim Submissions

Claims submitted by participating providers must include the following information:

Field	Information Required
Carrier ID	NB
Group Number or Code	Plan Identification Letter (see below)
Client ID	Patient’s Plan ID number or Medicare number (see below)
Patient Code (NB Drug Plan only)	Patient’s ID number (see below)
Patient Name	Patient’s first and last name
Patient DOB	Patient’s date of birth
Prescriber ID	Prescriber’s license or registration number (see below)
Prescriber ID Reference Code	Code identifying a prescriber’s licensing body (see below)
DIN / PIN	Drug Identification Number / Product Identification Number
Quantity	Quantity dispensed
Days Supply	Number of days’ supply dispensed (see below)
Drug Cost / Product Value	Please refer to Dispensing Fees and Drug Cost Reimbursement
Cost Upcharge	Please refer to Dispensing Fees and Drug Cost Reimbursement
Professional Fee	Please refer to Dispensing Fees and Drug Cost Reimbursement

Backdating and resubmission of electronic claims is permitted within 90 days of the dispensed date. Reimbursement of manual claims will be considered by the New Brunswick Drug Plans in the following exceptional circumstances:

For reversal of claims greater than 90 days ago
Resubmission of a claim as a result of a pharmacy audit

Manual claims must be submitted to the New Brunswick Drug Plans using the Manual Claim Form.

Group Number or Code and Patient ID

The table below specifies the information required to identify the Group Number or Code and Patient ID.

Plan	Group Number or Code	Patient ID
New Brunswick Prescription Drug Program (NBPDP)
Seniors	A	Plan ID Number
Correctional Facilities	C	Client Information System (CIS) ID Numbers must be 9 digits. Pharmacies must use leading zeros followed by the CIS ID Number (e.g. 000123456, 000000123)
Social Development Clients	F	Plan ID Number
Adult Residential Facilities	E	Plan ID Number
Children in the Care of the Minister of Social Development and Special Needs Children	G	Plan ID Number
Nursing Home Residents	V	NB Medicare Number
Cystic Fibrosis	B	Plan ID Number
Growth Hormone Deficiency	T	Plan ID Number
HIV/AIDS	U	NB Medicare Number
Multiple Sclerosis	H	Plan ID Number
Organ Transplant	R	Plan ID Number

The New Brunswick Drug Plan	D	Plan ID Number

Other Government Sponsored Plans
Medical Abortion Program	J	NB Medicare Number
Public Health Plan	I	NB Medicare Number
Tuberculosis	P	NB Medicare Number
Extra-Mural Program Clients	W	NB Medicare Number

For out of province patients, please refer to the NB Drug Plans Policy Manual.

Prescriber ID and Reference Code

Effective May 3, 2016, prescription claims submitted to the New Brunswick Drug Plans must include the prescriber’s license or registration number, as well as the corresponding Prescriber ID Reference Code which identifies the prescriber’s licensing body.

A prescriber’s license or registration number can be obtained by:

Accessing the Electronic Health Record (to gain access to the EHR, contact privsectaccess@gnb.ca)
Contacting the prescriber's office directly
Accessing the licensing body's web page

A default ID can only be used when:

A New Brunswick prescriber’s license or registration number is unknown. Repeated use of default IDs in cases where a Prescriber ID exists will be subject to audit.
The prescriber is from out-of-province.

The table below specifies the information required to identify the prescriber.

Prescriber		Field
Location	Type	Prescriber ID	Prescriber ID Reference Code
New Brunswick	Dentist	License number	45
	Physician	License number¹	41
	Pharmacist	License number	46
	Nurse Practitioner	Registration number	48
	Optometrist	License number	47
	Midwife	Registration number	99
	Podiatrist	License number	42
New Brunswick² (unknown license or registration number)	Dentist	D1	45
	Physician	D3	41
	Pharmacist	D5	46
	Nurse Practitioner	D7	48
	Optometrist	D9	47
	Midwife	D11	99
	Podiatrist	D13	42
Out-of-Province	Dentist	D2	See table
	Physician	D4
	Pharmacist	D6
	Nurse Practitioner	D8
	Optometrist	D10
	Midwife	99	99
	Podiatrist	D14	42

¹ A physician’s license number is preceded by two digits and a dash. The two digits represent the year in which the physician was licensed. Do not include these first two digits or the dash in the Prescriber ID field.

²Repeated use of default IDs in cases where a Prescriber ID exists will be subject to audit.

Days’ Supply for Claim Submissions

All claims submitted to NB Drug Plans must have the correct number of days’ supply for the dispensed quantity of drug. Refills submitted before 80% of the previous days’ supply have elapsed are subject to audit and recovery.

Related policies are listed below:

Maximum Days’ Supply

All claims submitted to the plans for reimbursement are subject to a maximum days’ supply. Details are outlined in the Maximum Days’ Supply Policy.

Designated High Cost Drugs

To reduce the potential for wastage, claims for designated high cost drugs that require special authorization (SA) are subject to a maximum days supply (e.g. 30 days) when administered at standard doses. Details are outlined in the Designated High Cost Drug Policy.

The SA drugs which this applies to are identified in the Maximum Allowable Price (MAP) List and Manufacturers List Price (MLP) List at Drug Price Lists and Pricing Policy.

Frequency of Dispensing and Payment

This policy establishes criteria for dispensing drugs taken continuously (long-term). Details are outlined in the Frequency of Dispensing and Payment Policy.

Submission of Claims over $9,999.99

Claims that exceed the maximum claim amount of $9,999.99 must be divided and submitted as separate transactions on the same day. The first transaction must use the DIN and contain the drug cost, mark-up and dispensing fee. The subsequent transactions must use the PIN, contain drug cost, applicable markup, and be submitted with Intervention and Exception Code “MG”. The fewest number of transactions must be used.

Transaction Information
Transaction	DIN/PIN	Dispensing Fee	Quantity	Drug Cost	Mark-Up	Days Supply	Copay	Intervention and Exception Code
First	DIN	Yes	Adjust quantity so that claim cost (including the applicable drug cost, dispensing fee, mark-up) does not exceed $9,999.99	Up to MAP/MLP. The amount must correspond to the quantity submitted in each transaction	Up to 8%. The amount must correspond to the quantity submitted in each transaction	Must correspond with the quantity being submitted in each transaction	Adjudication system will deduct copay from the first transaction only	Leave Blank
Subsequent transactions	PIN	No						MG

Example
Drug Cost: $24,000 (Up to MAP/MLP)
Mark-Up: $1,920 (Up to 8%)
Quantity: 60 tablets
Days Supply: 30

Transaction	DIN/PIN	Dispensing Fee	Quantity	Drug Cost Up to MAP/MLP	Mark-Up up to 8%	Days Supply	Copay	Intervention and Exception Code
First	DIN	Yes	23 tablets	$9,200	$736	12	Yes	Leave Blank
Second	PIN	No	23 tablets	$9,200	$736	11	No	MG
Third	PIN	No	14 tablets	$5,600	$448	7	No	MG

The drugs and applicable DINs and PINs that are included in this policy are listed here.

Claims submitted that do not comply with the above requirements are subject to audit and recovery.

Quantities for Claim Submissions

Please refer to the Maximum Allowable Price (MAP) List and Manufacturers List Price (MLP) List at Drug Price Lists and Pricing Policy to confirm the correct quantity for claim submissions for a specific product.

The unit of measure (quantity) for billing methadone for the treatment of opioid use disorder is milligrams. For example, a 70 mg dose of methadone should be billed with a quantity of 70.

Pharmacy Audits

All claims submitted to the Plans for reimbursement are subject to audit and recovery. Additional information regarding audit and recovery is available on the Pharmacy Provider Audit web page.