Non-Insured Health Benefits (NIHB) Newsletter for Dental Providers - Spring
2002
News and Information for Our NIHB Providers
First Canadian Health
NIHB Toll-free Inquiry Centre: 1-888-471-1111
For our Dental Practitioners
Fall/Winter 2001 - Spring 2002
News and Views
Welcome to the combined fall/ winter 2001 and spring 2002 edition of our quarterly
newsletter for the year 2001-2002. We are now into our fourth year of operations
as the claims processor for the NIHB Program of the First Nations and Inuit
Health Branch (FNIHB) of Health Canada.
Again, First Canadian Health (FCH) would like to thank you for your support
as you continue to provide quality health services to First Nations and Inuit
clients of the NIHB Program. As always, your comments and questions are welcome.
Please call our Toll-Free Inquiry Centre Representatives at 1-888-471-1111,
or send your correspondence to:
FCH Provider Relations
3080 Yonge Street, Suite 3002
Toronto, ON M4N 3N1
NIHB Dental Claim Processing System Upgrades
We will be upgrading the NIHB dental claims processing system on March 30
th , 31 st and April 1 st . As the system upgrades will occur in the background,
we do not anticipate any service disruptions during these three days.
As a result of these system upgrades, the format of the NIHB PD Confirmation
Letter and NIHB Dental Claims Statement will be enhanced to include new fields.
System upgrades will also include new and amended reject/ warning messages
on the NIHB Dental Claims Statement.
Should you have questions on the upgrades to the NIHB dental claims processing
system, please contact the FCH NIHB Toll-Free Inquiry Centre at 1-888-471-1111.
New, Changed and Deleted Reject/Warning Messages
The NIHB dental claims processing system assigns three-character reject and
warning codes that appear along with text explanations on your NIHB Dental
Claims Statement. Reject codes are composed of an "R" followed by
two numeric characters. The codes and corresponding text messages explain why
a claim was rejected. Warning codes are composed of a "W" followed
by two numeric characters. The codes and corresponding text messages explain
that a claim was processed but with modifications. As part of the upgrades
to the current NIHB dental claims processing system, new messages have been
introduced and some existing messages amended.
New Messages:
R28 CLIENT, PROVIDER OR BENEFIT DETAILS ON CLAIM DO NOT MATCH
PREDETERMINATION LETTER
R39 INVALID PROCEDURE CODE
R43 LAB FEE MUST BE SUBMITTED FOR SPECIFIED PROCEDURE CODE
R44 LAB OR EXPENSE FEE NOT ALLOWED FOR SPECIFIED PROCEDURE
CODE
R45 INVALID LAB OR EXPENSE PROCEDURE CODE
R47 THRESHOLD EXCEEDED. BENEFIT REQUIRES PREDETERMINATION
R66 DATE OF SERVICE MUST BE AFTER DOB
W13 PLEASE NOTE CORRECTED PROVIDER NO. FOR FUTURE CLAIMS
W27 PRE-VERIFICATION FOR THIS ITEM HAS BEEN USED UP BY PREVIOUSCLAIM
W31 REDUCED TO MAXIMUM SURFACES ALLOWED PER TOOTH INCLUDING
PREVIOUS CLAIM
W32 DUPLICATE SURFACE ON PREVIOUS CLAIM. PAYMENT LIMITED
TO UNIQUE SURFACES
Amended Messages :
R10 INVALID PROVIDER NO.
R30 CLIENT HAS ALTERNATIVE COVERAGE. CONTACT FNIHB
W10 THIS IS A CLAIM REVERSAL
Edit for Same-day Extractions in the Same Quadrant
The system edit for extractions on the same date of service in the same quadrant
has been expanded to include all extraction procedure codes (removal of erupted
teeth and surgical removals).
If a paid extraction is found in the same quadrant on the same date of service,
the warning message W30 "CLAIM REDUCED FROM SINGLE TO ADDITIONAL EXTRACTION,
SAME QUADRANT" will appear on your statement for the claim line in question.
Submission of Lab Fee on the NIHB DENT-29 Form
All procedure codes which are eligible for lab fees must be submitted with
a professional fee amount and a lab fee amount on the same claim line. If a
lab fee amount is not submitted for a lab eligible procedure code, the claim
line in question will be rejected with the R43 message, "LAB FEE MUST
BE SUBMITTED FOR SPECIFIED PROCEDURE CODE".
Claim Reversals
Please note, if a claim line must be reversed on a claim document, all claim
lines on that claim document have to be reversed. The reversed claim will appear
on the NIHB Dental Claim Statement. The W10 code will be printed next to each
claim line for the reversed claim. The corresponding message (" THIS IS
A CLAIM REVERSAL") will appear at the end of the statement.
Predetermination Confirmation Letter Enhancements
The following improvements will be made to the Predetermination Confirmation
Letter:
- Multiple letters produced on the same date for a provider will be mailed
in one envelope.
- The provider number will be printed following the client details.
- Start and end dates for predetermination will be printed for each approved
procedure code.
- A reminder note 'THE ABOVE PREDETERMINATION NUMBER AND PROVIDER NO. MUST
BE QUOTED ON YOUR CLAIM' is printed at the bottom.
NIHB Dental Claim Statement Enhancements
The following improvements will be made to the NIHB Dental Claim Statement:
- Response codes (reject and warning codes) have been repositioned to the
right hand side of the statement.
- Where a credit balance is owing to FCH, the credit balance portion will
be expanded to include the following terms:
- Total Net Amount (net amount paid for all claims on
current statement).
- Credit Balance Forwarded (amount owing to FCH prior
to the current statement run, expressed as a negative amount).
- Current Credit Balance (if applicable, the amount
owing to FCH after the current statement run, expressed as a negative
amount).
- Total Net Amount - Credit Balance Forwarded =
Current Credit Balance
The following fields will be added in place of the existing DOC/ INV No. field
on the statement:
- CLAIM/ REG No. (registration number assigned by FCH).
- DOC NO. (document number from the NIHB DENT-29 form, pre-printed at the
bottom right hand corner).
The following fields will be deleted from the statement:
- BAND (the client's band number).
- FAMILY (the client's family number).
NIHB DENT-29 FORM USED AS A CLAIM
As of August 1, 2001, claims must be submitted to FCH on NIHB DENT-29 forms
printed by FCH on or after December 1998. Any other claim forms will be returned
to you.
If your office claims for dental services rendered to NIHB clients using Standard
Dental Claim Forms, an NIHB DENT-29 form printed after December 1998 must be
attached.
Please request new NIHB DENT-29 forms from the FCH NIHB Toll-Free
Inquiry Centre and destroy any NIHB DENT-29 forms currently in your office
if the date on the form is prior to December 1998. (Date of form
is located in bottom left hand corner margin.)
REQUIREMENT FOR CLIENT SIGNATURE
The signature of the client or parent/ guardian is mandatory for all claims
and must be on the NIHB DENT-29 form.If the client signature field
is not completed, the claim will be returned to the provider.
In the case of children under the age of consent (16 years of age) who attend
subsequent dental appointments without a parent or guardian, 'signature on
file' must appear in the client, parent/ guardian signature field on the NIHB
DENT-29 form, and a signed NIHB DENT-29 form must be retained in the
patient's chart. This is an important policy from the point of view
of provider liability and program audit requirements.
ClaimCorrection and Resubmission
The NIHB Dental Claims Statement must be used to reconcile your accounts and
should be referenced when making inquiries. Corrections to claims must be indicated
directly below the existing information on the NIHB Dental Claim Statement
and a photocopy forwarded to First Canadian Health within 60 days of the statement
date for re-adjudication of the claim.
Do not alter or erase the existing information. Do not resubmit the claim
on a new NIHB DENT-29 form, by fax, or on a photocopied NIHB DENT-29 form.
Claims resubmitted by these methods will be returned.
"Post Approval " of Dental Treatment
All data elements necessary for a claim submission to FCH are mandatory for
Post Approval of services on the NIHB DENT-29 form. Forward Post Approvals
to the Regional FNIHB Offices for consideration. (If all data elements are
included on the NIHB DENT-29 form, FNIHB will forward the document to FCH for
processing once they have reviewed the form and issued a PD number where request
for predetermination has been granted.) Otherwise, a back-dated PD number will
be issued for eligible services and the form will be returned to you.
- NIHB DENT-29 form printed on or after December 1998 (as indicated in the
bottom left margin);
- Post Approval must be written clearly at the top of the NIHB DENT-29 form;
- The 'For Claim' box should be ticked;
- A client's complete mailing address, including a postal code, must be
indicated and legible;
- A provider's complete mailing address and unique provider number must
be indicated and legible;
- A payee's name and address must be indicated for all clients who are under
sixteen years of age if Pay Client/ Guardian box is checked off;
- The signature of client over the age of 16 must be provided;
- The signature of parent/ guardian must be provided for children under
the age of consent or an NIHB DENT-29 form must be completed with "Signature
on File" in the case of children under the age of consent, attending
subsequent dental appointments without a parent or guardian. An NIHB DENT-29
form with the original parent or guardian's signature must be retained in
the patient's chart;
- The office verification stamp or signature of the provider must be provided;
- Date of service must be indicated on all claim lines as well as all service
details such as procedure codes, tooth codes and, as applicable, surfaces,
quadrant, sextant or arch information.
- A professional fee, laboratory fee and total fee must be indicated for
each procedure line;
- Pre-verification numbers must be indicated, if applicable;
- Part 2 of the NIHB DENT-29 form must be completed; and,
- Part 3 of the NIHB DENT-29 form must be completed in its entirety including
missing teeth. An EOB must be attached to the NIHB DENT-29 form if co-ordination
of benefits applies.
Long Plain (Band 287)
As of October 1, 2001, the NIHB Program will no longer process dental claims
for client from Long Plain Band, 287.
Claims with a date of service after October 1, 2001, regardless of whether
they have been predetermined by the Regional FNIHB Offices, must be sent to
the Long Plain Dental Manager for payment.
Ms. Marg Myran A/Program Manager
Long Plain Dental Program
Box 580,
Portage la Prairie, Manitoba
R1N 3B9
For information on Long Plain client eligibility, or to obtain information
on the Long Plain Dental Plan, please contact the Long Plain office at 1-888-834-9768
or fax your request for information to (204) 252-2151.
Until February 1, 2002, FCH will continue to forward claims submitted in error
to FCH to the Long Plain Dental Manager. As of February 2, 2002, FCH will return
inappropriately submitted claims to the provider for resubmission to the Long
Plain Dental Manager.
Anishinaabe Mino-ayaawin Inc. (AMA) Clients
As of October 1, 2001, the NIHB Program will no longer process dental claims
for clients from Anishinaabe Mino-Ayaawin Inc. (AMA) which includes the following
Bands:
Band 268 - Kinonjeoshtegon
Band 269 - Peguis
Band 271 - Lake Manitoba
Band 272 - Fairford
Band 274 - Little Saskatchewan
Band 275 - Lake St. Martin
Band 316 - Dauphin River
Claims with a date of service after October 1, 2001 regardless of whether
they have been predetermined by a Regional FNIHB Office, must be sent to the
AMA Dental Manager for payment.
Dr. Ron Monczka
Program Manager
AMA Dental Program
401-286 Smith Street
Winnipeg, Manitoba
R3C 1K4
For information on AMA client eligibility, or to obtain information on the
AMA Dental Plan, please contact the 3 3 Page 4 Published quarterly by First
Canadian Health Management Corporation Inc. at 3080 Yonge Street, Suite 3002,
Toronto ON, M4N 3N1 AMA office at 1-888-486-4960 or fax your request for information
to (204) 943-2134.
Until February 1, 2002, FCH will continue to forward claims submitted in error
to FCH to the AMA Dental Manager. As of February 2, 2002, FCH will return inappropriately
submitted claims to the provider for resubmission to the AMA Dental Manager.
New Telephone Number and Fax Number for the Nisga'a Valley Health Board
Dental providers requiring predetermination for services to Nisga'a First
Nations must call 1-888-233-2212 or (250) 633-5000, or fax requests to the
Nisga'a Valley Health Board NIHB office at (250) 633-2512.
For information on Nisga'a First Nations client eligibility, or to obtain
information on the Nisga'a Valley Health Board Dental plan, please contact
the Nisga'a Valley NIHB office at 1-888-233-2212.
The Nisga'a Valley Health Board represents the following First Nations Bands:
671 - Gingolx (Kincolith)
677 - Gitlakdamix (New Aiyanish)
678 - Lakalzap (Greenville)
679 - Gitwinksihlkw (Canyon City)
Attached is a replacement NIHB Dental Practitioner Information Kit (DPIK).
The revised kit includes updated dental messages, claim form, confirmation
letter and statement samples resulting from the NIHB dental claims processing
system upgrade. Please replace all existing kit pages with this revised kit.
Published quarterly by First Canadian Health Management Corporation Inc. at
3080 Yonge Street, Suite 3002, Toronto ON M4N 3N1
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