Non-Insured Health Benefits (NIHB) Newsletter for Dental Practitioners - Winter 2005-2006

News and Information for Our NIHB Providers

NIHB Toll-free Inquiry Centre: 1-888-471-1111

For our Dental Practitioners - Winter 2005-2006

• Next Day Claims Verification (NDCV) Program for Endodontic Codes 33111 and 33100
• Attention: Claims Submitted for Endodontic Codes 33111 and 33100
• Claim Submissions on NIHB DENT-29 Form
• NIHB Dental Program Changes Effective October 1, 2005
• Ensuring Prompt Payment of Claims
• Change of Provider Contact Information
• Submission of Laboratory Fees
• Medical Care Program (MCP) in Newfoundland and Labrador
• NIHB Periodontic Policy (Quebec Only)

News and Views

Next Day Claims Verification (NDCV) Program for Endodontic Codes 33111 and 33100

The NDCV program will review all claims submitted for codes 33111 and 33100 on non-anterior teeth the day following receipt by FCH.

Predetermination for procedure codes 33111 and 33100 on molar and bicuspid teeth remains mandatory. Claims submitted for codes 33111 and 33100 for non-anterior teeth without a predetermination number will be returned to providers or clients unprocessed.

Should you have any questions or concerns, please contact the FCH NIHB Toll-Free Inquiry Centre at 1-888-471-1111.

Attention: Claims Submitted for Endodontic Codes 33111 and 33100

In order to ensure payment without rejection with the error message R50 (Frequency Of The Claim Exceeds The Maximum Allowed) for procedure codes 33111and 33100 on anterior teeth 13-23 and 33-43, it is recommended that providers contact their FNIHB Regional Office to obtain a predetermination number that must be provided on the claim submission.

Claim Submissions on NIHB DENT-29 Form

To avoid claims being rejected or returned unprocessed to providers, the NIHB DENT-29 Form must still be used for:

• Pay client claims
• Client reimbursements
• Claims payable to a third party

Providers can have a copy of the NIHB DENT-29 Form faxed to them by contacting the FCH NIHB Toll-Free Inquiry Centre at 1-888-471-1111.

NIHB Dental Program Changes Effective October 1, 2005

The NIHB Regional Dental Benefit Grid has several new important changes to the Program, such as:

• Implementation of a revised grid which clarifies what services require predetermination by placing benefits into one of the following two schedules:
  • Schedule A: Outlines services that may be completed and billed directly to FCH for payment; and
  • Schedule B: Outlines services that require predetermination.

Revised grids which reflect all Program changes have been sent to providers by FNIHB.

Please contact the FCH NIHB Toll-Free Inquiry Centre at 1-888-471-1111 if you have not received a copy.

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 1^st and 15^th 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 manual claim form submission
• R49 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 Claims 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 (Schedules A and B).

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, or Program guideline violations.

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 (when applicable)

Certain dental procedures require predetermination from FNIHB. These procedures are outlined in the current NIHB Regional Dental Benefit Grid (Schedule B). To obtain a predetermination, providers must submit the request manually to the FNIHB Regional Office using any of the following accepted forms:

• NIHB DENT-29 Form
• Standard Dental Claim Form
• ACDQ Dental Claim and Treatment Form
• Computer Generated Form

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 claim form are completed

Providers are reminded to complete all the required data elements of the claim form as outlined in Section 6.2 of the NIHB Dental Practitioner Information Kit . Failure to complete the required data elements on the claim 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)

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 payments and/or important provider communication.

Submission of Laboratory Fees

When submitting claims for procedure codes eligible for laboratory fees, the professional fee amount and the laboratory fee amount must be on the same claim line. Laboratory eligible procedure codes submitted without a laboratory amount on the same claim line will be rejected with the message R43 Lab fee must be submitted for specified procedure code. Laboratory fees submitted as separate procedure codes will be rejected with the message R04 This is not an eligible benefit.

Medical Care Program (MCP) in Newfoundland and Labrador

Providers in the province of Newfoundland and Labrador are advised that both the "Submission File Listing" and the "Reconciliation Detail Listing" must be attached to claims submitted for children covered under MCP. Failure to do so will result in a claim being rejected with the rejection message R20 Submit Claim to Provincial/Territorial Health Plan.

NIHB Periodontic Policy (Quebec Only)

The NIHB policy for prophylaxis and scaling combination remains unchanged as written in the NIHB Dental Framework and Periodontic Policy documents which have been recently sent to providers.

Published quarterly by First Canadian Health Management Corporation Inc. at 3080 Yonge Street, Suite 3002, Toronto, ON M4N 3N1