Dental Bulletin - September 2001

Dental Bulletin
Non-Insured Health Benefits Program

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Welcome to the third edition of the NIHB Dental Bulletin. This bulletin outlines important modifications to the dental predetermination process under Non-Insured Health Benefits (NIHB). These modifications were negotiated with the Alberta Dental Association, and after concurrence with the Canadian Dental Association are being implemented nationally on September 1, 2001.

The modifications will eliminate the waiting time prior to basic treatment, in addition it will streamline the claims process by eliminating the needs for amendments for basic care. It will also reduce the number of payment rejections by the claims processor because claims will not conflict with approved procedures. (except for Quebec providers)

"Post Approval" of Dental Treatment (except for Québec providers)

Effective September 1, 2001 the opportunity for post approval of dental treatment will be expanded. Dental providers will be able to submit for post approval with appropriate narratives and x-rays, those procedures that do not require predetermination regardless if the treatment provided exceeds the $600.00 threshold.

Those procedures that are marked with a "P" in your NIHB Regional Dental Benefit Grid, continue to require predetermination prior to commencing treatment.

Complete treatment plans must continue to be submitted, identifying those services requiring post-approval and those for predetermination. Providers are cautioned to be aware that the treatment provided is in accordance with the NIHB program terms and conditions as outlined in the Dental Provider Information Kit. For example, age or quantity limitations, for scaling/ root planning.

Providers must submit post-approvals to the First Nations and Inuit Health Branch (FNIHB) regional office for adjudication as per the post approval requirements in your Dental Provider Information Kit, Section 3.6, Post Approval. Post Approval should be clearly written in the area above Part 1 of the DENT29 form and the date of service for all procedures must be indicated.

Where pre-verification (PV) has been obtained from First Canadian Health (FCH) for procedures with a frequency guideline, the PV number should be indicated in the PV/ PD column of the DENT29 form. In cases where there is coordination of benefits (COB) the Explanation of Benefits (EOB) must be attached to the form in order for the claim to be forwarded to FCH for payment.

Post approval treatment plans with ALL procedures approved will be forwarded to FCH for payment by the regional dental unit. Post approvals with denied services and predeterminations will be returned to the provider via the original DENT29 form and/ or the confirmation letter process. This will ensure providers are aware of the denied procedures and can submit supporting information if required.

Disponible en français "Our mission is to help the people of Canada maintain and improve their health" 1 1 Page 2 DENT29 form with both post approvals and predetermination procedures will be processed as predetermination only.

Providers may wish to continue to request predetermination prior to initiating treatment for all procedures. This will eliminate provider risk as the program will confirm what will be funded prior to treatment. Providers continue to be responsible to ensure they receive payment within the one year period from the date the service is delivered.

Post approval services should be submitted with the required data elements completed on the DENT29 form.

Coordination of Benefits for Orthodontic Care

As of August 1, 2001 coordination of benefits with third party carriers will now be coordinated at the FNIHB regional office at the time of predetermination. Dental providers are required to attach the Explanation of Benefits (EOB) from the third party carrier when submitting for orthodontic treatment.

This change will reduce rejections and the need for communication with providers for clarification by FCH.

Maximum Allowable Quantities for Codeine-Containing Analgesics

Effective July 1, 2001, a quantity limitation will be implemented for products, containing codeine 30mg in combination with either acetaminophen or acetylsalicylic acid and with or without caffeine. A total of 1080 tablets will be allowed in a 90-day period. All paid claims for any codeine 30 mg combination analgesic product will be counted toward the maximum allowable quantity.