Orthodontic Bulletin
August 2004
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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.
Visit our Web Site at:
http://www.hc-sc.gc.ca/fnihb/nihb
The purpose of this bulletin is to:
- clarify the orthodontic benefits funded under the NIHB Program;
- announce there will now be no age restriction for dental-facial
anomalies;
- introduce a new standardized option for final payment (P1400).
Funding Criteria
NIHB is a publicly funded Program that covers a limited range
of orthodontic benefits for eligible First Nations and Inuit. Clients
must meet the clinical criteria and guidelines established by the
NIHB Program for their orthodontic treatment to be funded.
A severe and functionally handicapping malocclusion is
characterized as:
- dento-facial anomalies such as cleft lip and palate. No
age restriction.
- a combination of marked skeletal discrepancy (AP, transverse,
and/or vertical) and a marked dental discrepancy (AP, transverse,
and/or vertical), with associated severe functional limitations.
The purpose of the treatment must be to resolve the identified
discrepancies. Age restriction of under 18 years.
Note: The complete list of NIHB Guidelines for Comprehensive
Orthodontic Treatment can be found in the Dental Practitioners
Information Kit (DPIK) and in the NIHB Orthodontic Bulletin dated
June 2002. Both documents can be found on the NIHB Web site.
Orthodontic Predertimantion Submission Requirements
The NIHB Program can only determine if a client meets the Program's
funding criteria by reviewing the client's records and treatment
plan. Health Canada relies on orthodontists to help individuals
submit the required information. Unfortunately, the Program cannot
provide orthodontic treatment funding if this information is not
submitted for review.
Orthodontic treatment funding requests submitted to the
Orthodontic Review Centre (ORC) must include:
1. A Narrative
- identify the condition for which the treatment is being requested.
- explain diagnosis and prognosis.
- note basic treatment completed to date; patient's oral hygiene
status; and motivation.
- include a detailed treatment plan.
- estimate duration of active and retention phases of treatment
and cost(s).
- identify additional relevant supporting information.
The above information can be submitted on either a NIHB Orthodontic
Summary Sheet; CAO Standard Information Form; or on the Orthodontist's
letterhead.
2. Complete Diagnostic Records
- diagnostic orthodontic models (trimmed)
- Cephalometric: radiograph(s) and tracing
- Photographs: 3 intra oral and 3 extra oral
- Panoramic radiograph or full mouth survey
3. A Completed NIHB Dent-29 Form
for more information refer to Dental Practitioners Information
Kit (DPIK)
Interceptive Treatment Submission Requirements
As a prevention initiative, funding will be considered
for the provision of interceptive orthodontic treatment (80000
series procedures) in the mixed dentition phase of dental development.
NIHB requires:
- Diagnostic records including working models and a panoramic
radiograph.
- A narrative indicating treatment objective(s), a treatment
plan, projected active treatment time and anticipated fee.
Orthodontic Payment Codes or Specific Wording
As per the May 2000 National Agreement between the Canadian
Association of Orthodontists (CAO), Health Canada and the Assembly
of First Nations, payment codes or the specific wording indicated
below must be used when submitting a claim.
Payment Structure for Comprehensive Orthodontic Treatment:
- P1000 or Examination
- P1100 or Diagnostic Records
- P1101 or Diagnostic Records and Examination
- P1200 or Initial Payment - initiation of treatment. You will
be reimbursed 30% of treatment fee.
- P1300 or Incremental Payment - 9 months after comprehensive
orthodontic treatment is initiated. You will be reimbursed 25%
of treatment fee.
- P1300 or Incremental Payment - 15 months after initiation
of comprehensive orthodontic treatment. You will be reimbursed
25% of treatment fee.
- P1400 or Final Payment - when active orthodontic treatment
has been completed. You will be reimbursed 20% of orthodontic
fee.
New - Orthodontic Final Payment Form
This one page form will satisfy the need for a National Standard
for final payment and reduce administration requirements. It can
be submitted by the provider upon completion of orthodontic treatment
and attached to the Dent-29 Form indicating "post approval". With
this form, pre/post orthodontic treatment records are not required
to be submitted to obtain final payment (P1400). A copy of this
form is enclosed. Additional forms can be obtained by contacting
the ORC.
Claim Submission Requirements to First Canadian Health (FCH)
Health Canada prefers that providers bill the NIHB Program directly
for services so there are no upfront charges to clients. However,
dental providers have the choice to request the patient pay and
seek reimbursement from the Program.
Provider Reimbursement
- indicate 'claim' on Dent-29 form
- complete a Dent-29 form
Client Reimbursement
- indicate 'claim' on Dent-29 form
- complete a Dent-29 form
- include the original receipt. This is required as proof of
payment
- Send claim to the Orthodontic Review Centre for processing
Please remember to forward all orthodontic treatmen requests
directly to the Orthodontic Review Centre and not to the NIHB
Regional Offices. Sending requests to the wrong office will result
in significant processing delays.
Orthodontic Review Centre
Non-Insured Health Benefits, Health Canada
First Nations and Inuit Health Branch
Graham Spry Building
250 Lanark Avenue, 6th Floor
Address Locator 2006C
Ottawa, Ontario K1A 0K9
Toll-Free Phone: 1-866-227-0943
Toll-Free Fax: 1-866-227-0957
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