Provider Audits - Dental
 The Provider Audit Program assesses that provider claims are billed
in compliance with the Terms and Conditions of the Non-Insured Health
Benefits Program.
The objectives of the First Canadian Health (FCH) Dental Provider Audit
Program are to ensure that all payments made against the Non-Insured
Health Benefits (NIHB) Program are in compliance with the Terms and Conditions
of the NIHB Program. More specifically this may include, but is not limited
to the following:
- Verification of licensure of providers;
- Detection of unsubstantiated claims;
- Presence of appropriate signatures on submitted claims;
- Existence of appropriate documentation supporting the payments made
against the NIHB Program.
Next Day Claim Verification Program
Client Confirmation Program
Provider Profiling Program
On-Site Audit Program
Reference Documents
Additional Information
The four (4) components of the FCH Dental Provider Audit Program are
outlined below:
Next Day Claim Verification Program
The Next Day Claim Verification Program consists of a review of a defined
sample of claims submitted by providers the day following receipt by
FCH. Claims meeting specified criteria set by the program are reviewed
to ensure adherence to program policy as well as standard accepted definitions
and practices;
Client Confirmation Program
The Client Confirmation Program consists of a quarterly mail out to
a randomly selected number of NIHB clients to confirm the receipt of
the benefit that has been billed on their behalf;
Provider Profiling Program
The Provider Profiling Program consists of a review of the billings
of all providers against selected criteria and the determination of the
most appropriate follow up activity if concerns are identified, and
On-Site Audit Program
The On-Site Audit Program consists of the selection of a focused sample
of claims for administrative validation with a provider's records through
an on-site audit. The sample of claims reviewed is proportionate to the
volume of NIHB clients serviced by the provider.
Reference Documents
- FCH Provider Information Kit;
- NIHB/FCH Newsletters -- issued quarterly; and
- NIHB Program Dental Bulletins.
Additional Information
 Providers
requiring additional information about the FCH/NIHB Provider Audit Program
may contact
the FCH Director of Provider Audit in writing.
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