Non-Insured Health Benefits (NIHB) Newsletter for Dental Providers
- Winter 2004-2005
NIHB Toll-free Inquiry Centre: 1-888-471-1111
For our Dental Practitioners
Winter 2004-2005
News and Views
Welcome to the Winter 2004-2005 edition of the
Non-Insured Health Benefits (NIHB) quarterly newsletter. First Canadian Health (FCH) is now in its sixth year of operations as the claims processor for the NIHB Program of the First Nations and Inuit Health Branch (FNIHB) of Health Canada .
Again, 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 contact the FCH NIHB Toll-Free Inquiry Centre at 1-888-471-1111 , or send your correspondence to:
FCH Provider Relations
3080 Yonge Street, Suite 3002
Toronto , ON M4N 3N1
Electronic Data Interchange (EDI) System for Real-time Processing
CDAnet/Réseau ACDQ registered providers are encouraged to submit claims to the NIHB Program using the EDI system. The EDI system quickly verifies that all claim submission requirements are met, thereby ensuring payments are included in the next payment run.
Effective December 17, 2004, providers who have a CDAnet/Réseau ACDQ alphanumeric office ID can be registered with FCH to submit claims electronically. Providers who have a CDAnet/Réseau ACDQ office ID with 4 numeric characters are not affected.
To register for EDI, or to determine if you have already been set up to submit NIHB claims through EDI, please call the FCH NIHB Toll-Free Inquiry Centre at 1-888-471-1111.
For further information on electronic claim submission through EDI, please refer to your NIHB Dental Practitioner Information Kit .
Claims Correction Procedure for Paper and EDI Claims
Paper claims rejected due to incorrect or missing information must be re-submitted with corrections noted on the NIHB Dental Claim Statement . Providers must also use the statement to request the reversal of paid claims.
EDI claims rejected due to missing or invalid data can be re-submitted through the EDI system within 7 days of the date of service. After this time, the provider must use the NIHB Dental Claim Statement to correct the claim, as described above. EDI claims can be reversed electronically on the claim submission date. Also, providers can submit the statement showing the paid claim to FCH, along with a note requesting the claim be reversed.
Corrections and reversal requests must be clearly indicated below the applicable claim information on the statement. FCH must receive the corrected statement within 60 days of the statement date for re-adjudication of the claim. Providers are also asked to submit the entire statement, not just the portion of the statement that applies to the claim in question. The entire statement is needed to ensure the prompt re-adjudication of the claim.
If a new NIHB DENT-29 form is used to correct a previously submitted claim, all mandatory data elements must be filled out accordingly. Supporting documentation (i.e., lab invoice, etc.) must be submitted with the new NIHB DENT-29 form.
Should you have any questions, please call the FCH NIHB Toll-Free Inquiry Centre at 1-888-471-1111.
Ensuring Prompt Payment of Claims
FCH is committed to ensuring that providers and clients receive prompt payment of their NIHB claims. For this reason, FCH has a standard paper claim processing time of 5 business days from the date of receipt. The processed claims appear on the NIHB Dental Claim Statement which is printed twice monthly, on the 1st and 15th of each month. Some claimed services may be rejected, or reduced due to NIHB Program guidelines. Many claims, however, are rejected during adjudication due to missing information, and other avoidable submission errors. These errors lead to delays in the payment of the claims.
In evaluating reasons for claim rejections, FCH has determined that the most frequent reasons that claims are returned unprocessed, or rejected on the statement are due to:
- Missing or incomplete information on the NIHB DENT-29 form
- R49 Benefit Requires Predetermination
- R47 Threshold Exceeded. Benefit Requires Predetermination
- R50 Frequency Of The Claim Exceeds The Maximum Allowed
- R30 Client Has Alternative Coverage. Contact FNIHB
- R28 Client, Provider Or Benefit Details On Claim Do Not Match PD Letter
- R05 Claimant Could Not Be Verified As An NIHB Client
A complete list of rejection and warning codes is included in Section 7.5 of the NIHB Dental Practitioner Information Kit . Many of these claim rejections can be avoided by using the services of the FCH NIHB Toll-Free Inquiry Centre, and by referring to the NIHB Dental Practitioner Information Kit and the NIHB Regional Dental Benefit Grid .
To avoid processing and payment delays, providers are encouraged to follow these principles.
Verify NIHB eligibility before performing services
Providers are encouraged to contact the FCH NIHB Toll-Free Inquiry Centre at 1-888-471-1111 to verify client eligibility prior to treatment. This ensures that claims are not rejected due to incorrect client identification information, program guideline violations, or services exceeding the $800.00 threshold. At the request of the provider, the FCH NIHB Toll-Free Inquiry Centre issues a pre-verification number once the provider, client, and procedure code(s) are verified as NIHB eligible. The pre-verification number must be entered in the applicable field on the manual or electronic claim submission.
Obtain predetermination prior to submitting the claim for payment
Certain dental procedures require predetermination from FNIHB. These procedures are outlined in the current NIHB Regional Dental Benefit Grid . In addition, any treatment that exceeds the $800.00 threshold per client per 12 month period for procedures not requiring predetermination must be predetermined. To obtain a predetermination, providers must submit the request manually on a NIHB DENT-29 form to the appropriate FNIHB Regional Office. This also applies to EDI claims requiring predetermination. The predetermination number must be entered in the applicable field on the manual or electronic claim submission.
Ensure that the required data elements of the NIHB DENT-29 form are completed
Providers are reminded to complete all the required data elements of the NIHB DENT-29 form as outlined in Section 6.2 of the NIHB Dental Practitioner Information Kit. Failure to complete the required data elements on the NIHB DENT-29 form may result in the claim being returned unprocessed to the provider for completion.
Examples of common missing data elements that will result in the claim being returned to the provider include:
- Incomplete client identification information
- Incomplete provider identification information
- Missing stamp or signed office verification/ signature of provider
Choose to receive payments for claims through electronic funds transfer (EFT)
Providers may elect to have payments deposited directly into their bank account through EFT. This method of payment ensures that the provider normally receives funds on the same day as cheques are issued by First Canadian Health. EFT also assures payment in the event of a postal disruption.
To initiate payments through EFT, please contact the FCH Toll-Free Inquiry Centre at 1-888-471-1111 to obtain a Provider Information Form .
For further information on the principles described above, please refer to your NIHB Dental Practitioner Information Kit
Change of Provider Contact Information
Providers are reminded to contact the FCH NIHB Toll-Free Inquiry Centre at 1-888-471-1111 when they have a change of address or telephone/fax number. Failure to do so may result in delivery delays for receiving payments and/or important provider communication.
Electronic Posting of the Ontario NIHB Regional Dental Benefit Grid on the Ontario Dental Association (ODA) Web Site
The recent publication of the Ontario NIHB Regional Dental Benefit Grid, which became effective September 1, 2004, contains some minor errors. An updated version of the grid is now posted on the members' side of the ODA website (www.oda.ca).
Quebec Lab Fees
The formula for calculating lab fees in Quebec for general practitioners and specialists will pay up to a maximum of 50% of the procedure code fee listed in the current Quebec Provincial Fee Guide. Claims for laboratory fees above the calculated percentage must be submitted to the FNIHB Regional Office for approval.
For further information on lab fee submissions, please refer to Section 2.4 of the NIHB Dental Practitioner Information Kit .
Providers can download a current version of the NIHB Dental Practitioner Information Kit from the NIHB website at:
www.hc-sc.gc.ca/fnihb-dgspni/fnihb/nihb
Providers without internet access can contact the FCH NIHB Toll-Free Inquiry Centre at 1-888-471-1111.
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