Dental Bulletin - August 2004

Dental Bulletin
Non-Insured Health Benefits Program

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The Non-Insured Health Benefits (NIHB) Program provides supplementary health benefits, including dental treatment, for registered First Nations
and recognized Inuit throughout Canada.

The purpose of this bulletin is to:

• provide clarification on predetermination,
  post approval and claim submissions
• provide the revised Endodontic Funding Policy.

First Nations And Inuit Health Branch (FNIHB) and First Canadian Health (FCH) Roles

FNIHB regional offices are responsible for:

• reviewing predetermination, post approval requests and amendments;
• responding to inquiries from NIHB clients;
• reimbursing clients for pre-paid services;
• addressing appeals.

FCH is responsible for:

1. claims processing;
2. confirming client eligibility;
3. confirming benefit eligibility;
4. providing pre-verification numbers;
5. providing payment information;
6. processing claim submissions;
7. responding to provider claim inquiries;
8. processing provider registration and provider file updates.

NIHB Regional Dental Benefit Grid

The NIHB Regional Dental Benefit Grid outlines dental benefits funded by the NIHB Program. To obtain a copy of a Regional Dental Benefit Grid, please contact the FCH NIHB Toll-Free Inquiry Centre at 1-888-471-1111. Providers in Québec Region are to contact their regional office at: 1-877- 483-5501.

Clarification

Predetermination

A complete treatment plan is required for predetermination submissions and must address:

• diagnostic;
• preventive;
• surgical;
• restorative;
• periodontic;
• endodontic; and
• prosthetic needs of the client.

All preventive and basic restorative treatment needs must be addressed before procedures requiring predetermination are initiated (e.g: root canal therapy, crowns, removable or fixed prosthetics).

All relevant supporting diagnostic documentation (e.g.: radiographs, models, periodontic charting if relevant) including narrative must accompany the treatment plan.

Diagnostic radiographs must be:

• recent;
• mounted;
• dated;
• diagnostic in quality; and
• indicate the provider and client name.

Duplicate radiographs must indicate if the radiograph is of the right or left in orientation. A notation of basic treatment that has been completed or in progress, client's oral hygiene status, and other relevant comments should be provided with the submission. Without complete information delays may occur in the adjudication of the request.

Post Approval

Procedures not marked with a "P" that are over the $800.00 threshold and are within guidelines may be post approved. Procedures marked with a "P" involved with providing immediate relief of pain (e.g. complex extractions, urgent denture repairs) will be considered for post approval as outlined in the DPIK section 2.9.2. Post approvals require the same diagnostic information as predetermination submissions.

Signature on File

NIHB requires that the signature of the client, parent, or 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. Signature on File requirement will be enforced effective July 1, 2004.

In the case of a child who attends subsequent dental appointments without a parent or guardian, "Signature on File" must appear in the "Signature of Client (Parent/ Guardian)" field on the NIHB DENT-29 form, and a signed NIHB DENT - 29 form must be retained in the patient's chart.

NIHB Dent-29 Form

The NIHB DENT - 29 form is used to request:

• predeterminations;
• post approvals;
• submit claims and client reimbursements.

Computer printouts and standard dental claim forms can be submitted when all data elements of the NIHB DENT - 29 form are included, and a NIHB DENT - 29 form is attached with client signature.

Tooth Charting (Part 3B)

Tooth charting is required for predetermination, post approval submissions and when a client is new or returning to the practice.

Amendments to Predeterminations

Minor amendments to predeterminations (e.g.: procedure code or surface code changes) may be made by phone, fax, or by submitting a NIHB DENT - 29 form to the Regional Predetermination Centre. Complete documentation (e.g.: Explanation of Benefits) is required if the form is to be forwarded to FCH for claims payment.

Appeal Process

Clients may appeal when funding for an eligible benefit has been denied.

NIHB will not accept appeals for services that are not benefits of the program. For example:

• Prefabricated / composite veneers;
• Ridge augmentation.

Three levels of appeal are available. Appeals must be initiated by the client at each level. Appeals must be accompanied by supporting information and documentation. A written explanation of the decision taken will be provided to the client, or to the clients representative, at each level of the appeal process.