Non-Insured Health Benefits (NIHB) Newsletter for Dental Providers
- Summer 2005
News and Information for Our NIHB Providers
First Canadian Health
NIHB Toll-free Inquiry Centre: 1-888-471-1111
For our Dental Practitioners - Summer 2005
News and Views
Welcome to the summer 2005 edition of the Non-Insured Health Benefits
(NIHB) quarterly newsletter. First Canadian Health (FCH) is now in its
seventh 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
New NIHB Regional Dental Benefit Grids for General Practitioners and
Specialists, and for Denturists
The new NIHB Regional Dental Benefit Grids for general practitioners
(GP) and specialists (SP), and for denturists (DT) for the following
provinces will be in effect as of::
July 1st , 2005
- British Columbia , GP & SP
- Manitoba, GP & SP
- Manitoba, DT
August 1st , 2005
- New Brunswick, GP
- New Brunswick, DT
- Newfoundland, GP
- Newfoundland, DT
- Nova Scotia, GP
- Prince Edward Island, GP
The new grids reflect the change in prices and eligible procedures.
They will be sent to you prior to the effective date.
Should you have any questions, please contact the FCH NIHB Toll-Free
Inquiry Centre at 1-888-471-1111 .
Removal of Threshold
Effective July 1st, 2005, the
$800.00 threshold will be removed from the system. Rejection message
R47 (THRESHOLD EXCEEDED. BENEFIT REQUIRES PREDETERMINATION) will no longer
exist. This means that a predetermination will only be required for codes
indicated as 'P' in the NIHB Regional Dental Benefit Grid .
All other predetermination guidelines remain unchanged.
Should you have any questions, please contact the FCH NIHB Toll-Free
Inquiry Centre at 1-888-471-1111 .
Endodontic Policy Change
Effective July 1, 2005, endodontic therapy on anterior teeth (13-23,33-43
inclusive) (procedure codes 33111 and 33100) may be completed without
predetermination. Predetermination for bicuspid and molar teeth remains
mandatory.
Attention:
In order to ensure payment without rejection (error code R50), and until
system changes can be made, it is recommended that providers contact
their FNIHB Regional Office to obtain a predetermination number that
must be provided on the claim submission.
NIHB DENT-29 Form Requirement Change
Effective July 1st , 2005, FCH
and the FNIHB Regional Offices will be accepting either one of the following
for manual claim, predetermination and post approvals submissions:
- Standard Dental Claim Form
- Computer generated form
- ACDQ Dental Claim and Treatment Plan Form
- NIHB DENT-29 form
It will no longer be necessary to attach a NIHB DENT-29 form to the
standard dental claim form, the computer generated form or the ACDQ dental
claim and treatment plan form. To avoid claims being rejected or returned
unprocessed to providers, all mandatory data elements (e.g. supporting
documents, tooth charting, client identification, and/or band name/band
number, family number, and date of birth) must be completed on the claim
form, with the exception of the client signature.
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 .
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.
Client Calls
Dental practitioners are requested to direct client inquiries to the
appropriate FNIHB Regional Office. Please refer to the Directory insert
in the pocket of your NIHB Dental Practitioner Information Kit for
the telephone number and address of each FNIHB Regional Office.
The FCH NIHB Toll-Free Inquiry Centre provides services to NIHB providers
only.
Electronic Data Interchange (EDI) System for Real-Time Processing
CDAnet and 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 in real-time.
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 .
Rejected Claims
First Canadian Health (FCH) is committed to ensuring that providers
receive prompt payment of their NIHB claims. Many claims are rejected
during adjudication due to avoidable submission errors. This leads to
delays in the payment of claims.
FCH has determined that the most frequent reasons why claims are rejected
on the NIHB Dental Claim Statement are:
R05 CLAIMANT COULD NOT BE VERIFIED AS AN NIHB CLIENT
The client verification problem may be due to:
- The claimant has not used his or her registered surname, given names
or date of birth; or
- The claimant has made an error in specifying the client identification
number.
In such cases, it may only be necessary for the client to provide more
accurate client identification information.
If the claimant is not registered as an NIHB client, however, the claimant
must register before services can be funded by the NIHB program.
R28 CLIENT, PROVIDER OR BENEFIT DETAILS ON CLAIM
DO NOT MATCH PD LETTER
The claim has not been paid because the client, provider or benefit details
on the claim do not match those on the predetermination confirmation
letter. If an error was made, supply the corrected information to FCH.
If the predetermination requires an amendment, providers must contact
the appropriate FNIHB Regional Office.
Providers must refer to the NIHB Predetermination Confirmation Letter
for details on predetermined services before submitting a claim to FCH.
R49 BENEFIT REQUIRES PREDETERMINATION
Certain dental procedures require predetermination from the First Nations
and Inuit Health Branch (FNIHB) in order to establish NIHB funding responsibilities.
These procedures are outlined in the current NIHB Regional Dental
Benefit Grid . To obtain a predetermination, submit the request
in writing with the supporting documentation to the appropriate FNIHB
Regional Office. The predetermination number must then be referenced
on the manual or electronic claim submission.
R50 FREQUENCY OF THE CLAIM EXCEEDS THE MAXIMUM ALLOWED
The claim has not been paid because the procedure code exceeds the maximum
allowed, as specified in the current NIHB Regional Dental Benefit
Grid.
To verify frequency limitations, providers are encouraged to consult
their NIHB Regional Dental Benefit Grid , and to call the FCH
NIHB Toll-Free Inquiry Centre at 1-888-471-1111 .
Address on the Predetermination Confirmation Letters for Orthodontic
Services
Effective June 1st 2005, all confirmation letters for orthodontic
services will indicate the address below:
Orthodontic Review Centre
Non-Insured Health Benefits
First Nations and Inuit Health Branch
Health Canada
Graham Spry Building
250 Lanark Avenue, 6th Floor
Postal Locator 2006C
Ottawa, ON K1A 0K9
Providers can download a current version of the NIHB Dental Practitioner
Information Kit at the NIHB website:
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 .
Published quarterly by First Canadian Health Management Corporation
Inc. at 3080 Yonge Street, Suite 3002, Toronto, ON M4N 3N1
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