Billing and Payment - Dental
The Non-Insured Health Benefits (NIHB) Program allows dental practitioners
to bill First Canadian Health (FCH) using one of these methods:
- Electronic claim submissions using the Electronic Data Interchange
(EDI) system;
- Manual claim form submissions; or
- Computer printout claim submissions.
Regardless of the billing method used, all required data elements
must be supplied to enable the efficient processing and payment
of claims.
Providers have one year from the date of service to secure payment.
Claims submitted with dates of service more than one year after
services have been rendered are rejected with the R21 message
(period for submitting claims has expired).
 Inquiries related to any of the available billing methods, format,
record layout or completion of a claim form must be directed to
the Non-Insured
Health Benefits Toll-Free Inquiry Centre.
Billing Methods
Electronic Claim Submissions
Manual Claim Submissions
Computer Printout Claim Submissions
Electronic Claim Submissions -- Electronic Data Interchange
(EDI)
Dental providers may submit electronic claims and same day reversals
for dental services using the EDI system, for real-time adjudication.
This option is available to dental practitioners 24 hours a day,
7 days a week.
All NIHB claims submitted using the EDI system are either accepted
or rejected in real-time; there are no suspended claims. Two types
of messages are generated for claims submitted using the EDI system:
Canadian Dental Association (CDAnet) and Réseau Association
des chirurgiens dentists du Québec (ACDQ) error codes
and NIHB Health Information and Claims Processing System (HICPS)
codes messages (see Dental Claim Submissions
Messages and Explanations)
Note: A list of required data elements for EDI
claims and an explanation of the data elements required for claims
submitted using the EDI system is found at Electronic
Data Interchange Required Data Elements.
Missing teeth information cannot be submitted on EDI claims. Missing
teeth must be recorded for all predetermination submissions and
all claim submissions for clients who are new to the practice or
returning from another dental practitioner. The tooth chart must
be kept in the client's file for audit purposes.
Claims Excluded from the Electronic Data Interchange (EDI) System
Certain claim submissions still require manual claim forms. If
these submissions are sent electronically, an acknowledgement is
returned to the provider requesting a manual submission.
The EDI system does not support:
 Manual Claim Submissions
Claims can be submitted manually on:
If there are any dental benefits or services provided under any
other group insurance or dental plan, Workers Compensation Board
(WCB), government plan or, if a result of an accident, a motor
vehicle or accident insurance plan, the provider is obliged to
attach to the claim form all predetermination details from the
third party carrier and the Explanation of Benefits (EOB).
All missing teeth information must be recorded on all predetermination
submissions.
Photocopies of claims are not accepted by FCH. An exception is
made if the original claim was not received by FCH. In this case,
the provider can submit a photocopy of the claim with "Resubmission" written
on it. In all other cases, the claim will be returned to the provider
unprocessed.
Computer Printout Claim Submissions
Computer printouts and standard dental claim forms can be submitted
if all data elements are present.
Billing for Pre-verified Treatment
Electronic Data Interchange Claim Submissions - Pre-verified
Treatment
When submitting a claim for a pre-verified procedure using the
EDI system, providers must record the pre-verification number in
the correct field (refer to Electronic Data
Interchange -- Required Data Elements) Since the EDI system
allows only one pre-verification number per claim, services involving
multiple procedures issued with different pre-verification numbers
must be submitted as separate claims.
Manual Claim Submissions - Pre-verified Treatment
When submitting a manual claim for a pre-verified procedure, providers
must record the applicable pre-verification number on the claim
line for the procedure code(s) submitted. If more than one procedure
code has been issued a pre-verification number, write the pre-verification
number next to each applicable claim line. Failure to write the
pre-verification number next to each applicable claim line may
result in the claim being rejected if another claim for the same
procedure has already been processed for the client.
Restrictions - Pre-verified Treatment
A pre-verification number is valid for up to six (6) months from
the date of issuance. Where a pre-verification number has been
issued and there is a third party coverage, an EOB form must accompany
the claim. Failure to submit with a service date within this timeframe
results in claims being adjudicated with warning message W28 (pre-verification
service date violation) or W29 (pre-verification
number is invalid).
Billing for Predetermined Treatment
EDI Claim Submissions - Predetermined Treatment
Although predetermination requests cannot be submitted using
the EDI system, the resulting claims may be submitted electronically.
When submitting a claim for predetermined services using the EDI
system, providers must record the predetermination number from
the Predetermination Confirmation Letter in the correct field (refer
to Electronic Data Interchange -- Required Data
Elements). Since EDI allows only one predetermination number
per claim, services involving multiple procedures issued with different
predetermination numbers must be submitted as separate claims.
Manual Claim Submissions- Predetermined Treatment
When submitting a manual claim for a predetermined procedure,
providers must record the applicable predetermination number on
the claim line for the approved procedure code. If more than one
procedure code has been issued a predetermination number, write
the predetermination number next to each applicable claim line.
Failure to write the predetermination number next to each applicable
claim line may result in the claim being rejected if another claim
for the same procedure has already been processed.
Restrictions - Predetermined Treatment
The details on the claim submission must match the details on
the Predetermination Confirmation Letter (for example, client identifiers,
procedure codes, tooth numbers, surface codes, quadrant, sextant
or arch codes). A "+L" indicated on the Predetermination
Confirmation Letter beside the "Maximum Amount Approved" column
indicates that a lab fee has also been approved. Only the provider
that has requested and received the Predetermination Confirmation
Letter is eligible to claim for reimbursement. Claims submitted
against a predetermination where details do not match the information
on the Predetermination Confirmation Letter are rejected with message R27 (predetermination
number is invalid) or R28 (client, provider or
benefit details on claim do not match pd letter).
Selected Billing Rules
The NIHB Program places billing restrictions on certain dental
services:
Orthodontic Payment Codes (not procedure codes)
Claims for comprehensive orthodontic services can only be
submitted manually. Payment codes or the exact wording indicated
must be used, or the claim form will be returned to the provider
unprocessed. Claims submitted using the existing comprehensive
procedure codes in the fee guide are rejected.
These are the orthodontic alpha-numeric payment codes, exact wording
must be used.
Examination -- payment code P1000
Diagnostic Records -- payment
code P1100
Diagnostic Records and Examination -- payment
code P1101
Initial Payment -- payment code P1200
Incremental Payment -- payment code P1300
Final Payment -- payment code P1400
Anaesthesia Services
When submitting an EDI or a manual claim for anaesthesia services,
the claim must be accompanied by the associated dental procedure
code with the same date of service. Failure to submit claim without
a verified associated code results in the claim line being rejected
with message R42 (associated dental procedure
must be specified).
Laboratory Fees
EDI Claim Submissions - Lab Fees
When submitting a claim using the EDI system for procedure codes
eligible for lab fees, the claim must be submitted with both the
professional fee amount and the lab fee amount on the same claim
line. Failure to do so results in the claim being rejected with
message R43 (lab fee must be submitted for specified
procedure code). While commercial invoices cannot accompany EDI
submitted laboratory fees, providers may be required to produce
an original lab invoice upon request by FCH for audit purposes.
For denturists, when the laboratory cost is included in the professional
fee, a laboratory invoice is not necessary.
Note: If two lab fees are submitted on the same
claim, the total lab fee allowed is returned in the eligible amount
for lab code 1 field.
Manual Claim Submissions - Lab Fees
When submitting a manual claim for procedure codes eligible for
laboratory fees, the codes must be submitted with both a professional
fee amount and a lab fee amount on the same claim line. It is not
mandatory for a laboratory invoice to be submitted with the claim;
however, providers may be required to produce an original laboratory
invoice upon request by FCH for audit purposes.
Note: If a provider attach a laboratory invoice to a claim and
the lab fee claimed is different from the amount on the laboratory
invoice, the claim will be returned to the provider unprocessed.
Dentures Lab Fees
When submitting either an EDI or manual claim for dentures for
which the denture code does not indicate either upper or lower
arch (for example, unilateral dentures) the provision of a quadrant
code, arch or a tooth code is mandatory. The arch identifier code
must appear in the int. tooth code field of the claim form. Failure
to supply the associated quadrant, arch or tooth code results in
the claim being rejected with message R38 (missing
or invalid tooth, surface, arch, quadrant or sextant code).
Universal Descriptions and Codes
When submitting either an EDI or manual claim for procedures that
require a/an quadrant, surface, arch or sextant description, providers
must use these codes:
Quadrant Codes and Descriptions:
- Code 10 for Upper Right
- Code 20 for Upper Left
- Code 30 for Lower Left
- Code 40 for Lower Right
Surface Codes and Descriptions:
- Code L for Lingual
- Code M for Mesial
- Code I for Incisal
- Code B for Buccal
- Code V for Labial Anterior
- Code F for Facial
- Code D for Distal
- Code O for Occlusal
Arch Codes and Descriptions:
- Code 00 for Full Mouth
- Code 01 for Maxillary
- Code 02 for Mandibular
Sextant Codes and Descriptions:
- Code 03 designates from 18-14
- Code 04 designates from 13-23
- Code 05 designates from 24-28
- Code 06 designates from 38-34
- Code 07 designates from 33-43
- Code 08 designates from 44-48
Dental Claims Reversal
Electronic Data Interchange Claim Reversal
The claim reversal transaction is used to reverse a previously
submitted and paid EDI claim submission. A claim may only be reversed
using the EDI system on the same day that it was submitted. To
reverse a claim after the date of submission, follow the manual
procedures outlined in Non-Insured Health Benefits Dental
Claim Statement Messages and Explanations.
To successfully reverse a claim, the provider must follow the
instructions provided by the dental software vendor.
When a claim reversal is submitted, an electronic claim reversal
response is sent to the provider . If the reversal is
accepted, the system reverses the impact of the original claim
and the original claim does not appear on the provider's statement.
If the reversal is rejected, the provider must correct the error(s)
and resubmit the claim reversal.
Manual Claim Reversal
A manual claim reversal is submitted on the NIHB Dental Claim
statement as outlined in Non-Insured Health Benefits Dental
Claim Statement Messages and Explanations.
Dental Claim Submissions Messages and Explanations
EDI Claim Submissions - Messages and Explanations
For every submitted transaction, the system generates a CDAnet
and Réseau ACDQ response status code to indicate
to the provider whether the transaction was accepted or rejected.
Once accepted, claims submitted using the EDI system are adjudicated
in a matter of seconds. Two types of codes/messages may be displayed
to inform providers of the outcome of the transaction: CDAnet and Réseau ACDQ codes/messages and NIHB system codes/messages:
- When a claim cannot be adjudicated in real-time because of
missing/invalid data, a Claim Acknowledgment is returned to the
provider with the CDAnet and Réseau ACDQ response
status code "R " indicating that the claim
is rejected because of errors. For every procedure
line that has an error, a valid CDAnet and Réseau ACDQ three-character numeric error code and text description
are displayed.
- When a claim cannot be adjudicated in real-time because it
must be submitted manually, a Claim Acknowledgment is returned
to the provider with the CDAnet and Réseau ACDQ response
status code "048 " indicating that
a manual claim form must be submitted by the provider.
- When a claim submission is accepted and processed, an electronic
response called Explanation of Benefits (EOB) is returned to
the provider with the results of the adjudication. If a reject "R" or
warning "W" NIHB message is generated as a
result of the claim adjudication, the EOB includes the NIHB "R" and "W" codes
and message text (in the Notes field). In addition,
NIHB messages on the EOB are also printed on the NIHB Dental
Claim Statement which accompanies the claims payment cheque or
electronic funds transfer notice.
- When a claim reversal is submitted, an electronic claim reversal
response is sent to the provider. The response indicates whether
the reversal is rejected or accepted. CDAnet and Réseau ACDQ error codes and text description may be displayed
in the Notes field.
For additional information on the Claim Acknowledgment, the EOB
and the standard CDAnet and Réseau ACDQ codes
refer to your CDAnet and Réseau ACDQ Dental Office
User Guide; for NIHB Health Information and Claims Processing System
(HICPS) codes and messages.
Manual Claim Submissions - Messages and Explanations
For manual claims, reject "R" or warning "W" NIHB
messages generated as a result of the claim adjudication are displayed
on the NIHB Dental Claim Statement which accompanies the claims
payment cheque or electronic funds transfer notice.
Dental Claims Payment
Claim payments to registered NIHB providers are issued twice per
month and contain payment for claims settled and paid through the
HICPS system administered by FCH (see Non-Insured Health Benefits Dental
Claim Statement Messages and Explanations.)
If the provider elects to have a claim cheque issued, the cheque
is sent out via regular mail with the NIHB Dental Claim Statement
which contains any additional information (for example, suspended/rejected
claims). If the provider has selected Electronic Funds Transfer
(see Method of Payment) rather than a cheque,
the funds are deposited and the NIHB Dental Claim Statement is
sent out via regular mail.
If the provider works in more than one office, the provider receives
separate cheques/electronic deposits and statements for each office
that has submitted claims within the period, provided the unique
identification number for each distinct office has been utilized
on claim submissions.
An administrative fee of $25.00 applies for duplicate statement
requests. Requests must be made in writing to FCH and include a
cheque for $25.00. If the FCH payment cheque corresponding to the
statement has not been cashed and a sufficient amount of time has
passed, the $25.00 administrative fee is not applied and the provider's
$25.00 cheque is returned with the requested copy of the statement.
Method of Payment
Providers may elect to receive payment for eligible claims directly
through electronic funds transfer into the provider's designated
bank account. This method of payment ensures that the provider
normally receives funds on the same day as payment is issued by
FCH, and that payment is assured in the event of postal disruption.
Upon completing the Provider Information Form, the provider must
elect to have payment through cheque or electronic funds transfer.
In addition, the provider may choose to change to electronic funds
transfer at any time. Simply complete the Provider Information
Form (contact the FCH Toll-Free Inquiry Centre
to obtain a copy of this form ) and fax or mail it to
the attention of FCH Provider Relations. This change may take two
(2) weeks to enact due to bank cut-off dates, but the electronic
funds transfer commences no later than the second claims statement
period after remitting the change.
Claim Submissions -- Required Data Elements
Electronic Data Interchange (EDI) -- Required Data Elements
The required data elements apply only to claims submitted using
the EDI system. Additional data elements may be required by the
dental office software provided by the software vendor. For information
about required data elements for manual claim submissions, see Manual
Claims Submission-- Required Data Elements.
Note: The names of the required fields displayed
on the dental office software may be different from the names of
the required data elements. For clarification of the field names
on the dental office software or assistance in submitting the required
data elements, providers may contact the software vendor.
EDI Claim Submission Required Data Elements for CDAnet
and Réseau ACDQ
List Terminology:
- Field ID
- Identifier given to the field.
- Field Name
- Text name given to the field.
- Non-Insured Health Benefit Description
- A description of what the field is used for
Field ID: A02
Field Name: Office Sequence Number
Non-Insured Health Benefit Description: A number
assigned by and under the control of the dental office software
provided by the software vendor.
Code: A03
Field Name: Format Version Number
Non-Insured Health Benefit Description: A 2-digit
code identifying the Version of the CDAnet and Réseau
ACDQ standard software used on the dental office software:
either 02 or 04.
In most cases, numbers are assigned automatically by the dental
office software provided by the software vendor. Only Version 4
is acceptable for NIHB claims.
Code: A04
Field Name: Transaction Code
Non-Insured Health Benefit Description: A 2-digit
code usually assigned automatically by the dental office software
to indicate the purpose of a transaction: valid NIHB codes are:
- 01 - Claim
- 11 - Claim Acknowledgement
- 21 - Explanation of Benefits
- 02 - Reversal
- 12 - Reversal Response
Code: A05
Field Name: Carrier Identification Number
Non-Insured Health Benefit Description: This 6-digit
unique number identifies the claims processor who receives the
transaction. In most cases, numbers are assigned automatically
by the dental office software provided by the software vendor.
The carrier identification number or BIN number for NIHB dental
claims transmission to FCH is 610124.
Code: B01
Field Name: CDA Provider Number
Non-Insured Health Benefit Description: This unique,
9-digit number has been assigned to you by CDA, and must be included
in every transaction.
Code: B02
Field Name: Provider Office Number
Non-Insured Health Benefit Description: This 4-character
identifier has been assigned to you by CDA, and must be included
in every transaction.
Code: C01
Field Name: Primary Policy/Plan Number
Non-Insured Health Benefit Description: This 6-digit
unique number identifies the client's insurance policy number.
In most cases, numbers are assigned automatically by the dental
office software provided by the software vendor. The policy/group
number for NIHB dental claims transmission to FCH is 080000 (leading "0" is
mandatory).
Code: C02
Field Name: Subscriber Identification Number
Non-Insured Health Benefit Description: The unique
number used to identify a client who is eligible to receive benefits
under the NIHB Program.
Code: C05
Field Name: Patient's Birthday
Non-Insured Health Benefit Description: The client's
full birth date in correct format.
Code: C06
Field Name: Patient's Last Name
Non-Insured Health Benefit Description: The surname
under which the client is registered as an NIHB client.
Code: C07
Field Name: Patient's First Name
Non-Insured Health Benefit Description: The given
names under which the client is registered as an NIHB client. Submission
of more than one given name is preferred to facilitate client verification.
Initials are not acceptable.
Code: D05
Field Name: Subscriber's Address Line
1
Non-Insured Health Benefit Description: First
line of client's address.
Code: D06
Field Name: Subscriber's Address Line
2
Non-Insured Health Benefit Description: Second
line of client's address, if applicable.
Code: D07
Field Name: Subscriber's City
Non-Insured Health Benefit Description: The client's
city.
Code: D08
Field Name: Subscriber's Province
The client's province.
Code: D09
Field Name: Subscriber's Postal Code
Non-Insured Health Benefit Description: The client's
postal code
Code: F01
Field Name: Payee Code
Non-Insured Health Benefit Description: This field
determines who should be paid. Valid codes are:
- 1 - Pay to client (subscriber)
- 2 - Pay to other third party
- 3 - Reserved
- 4 - Pay to dentist
Code: F03
Field Name: Predetermination Number
Non-Insured Health Benefit Description: For a
claim that has been predetermined and approved in part or in full,
the predetermination number indicated on the FNIHB confirmation
letter must be entered.
For a claim for pre-verified services, the pre-verification number
(V-prefixed number) must be entered.
When a predetermination or pre-verification number is entered
on an EDI claim document, all claim lines on the document must
pertain to the entered predetermination or pre-verification number.
Code: F07
Field Name: Procedure Line Number
Non-Insured Health Benefit Description: The line
number of the procedure in the claim submission. The line number
will be preserved in the Claim Response. In most cases, this number
is assigned automatically by the dental office software provided
by the software vendor.
Code: F08
Field Name: Procedure Code
The procedure code corresponding to the applicable procedure.
Code: F09
Field Name: Date Of Service
Non-Insured Health Benefit Description: The date
on which services were provided to the client in day/month/year
format (for example, 13/07/1999 represents 13 July 1999). For procedures
requiring more than one appointment, where an insertion is required,
the date of service must be the date when the service was inserted.
Contact your FNIHB Regional Office if insertion cannot occur.
For procedures requiring more than one appointment that do not
require an insertion, the date of service must be the date when
the service was completed.
bcF10
Field Name: International Tooth, Sextant, Quad Or Arch
Non-Insured Health Benefit Description: The international
tooth number, quadrant, sextant or arch code corresponding to the
procedure for which tooth number, quadrant, sextant or arch description
is mandatory.
Code: F11
Field Name: Tooth Surface
Non-Insured Health Benefit Description: The surface
code corresponding to a procedure for which surface description
is mandatory.
Code: F12
Field Name: Dentist's Fee Claimed
Non-Insured Health Benefit Description: The dollar
amount claimed for professional services.
Code: F13
Field Name: Lab Procedure Fee # 1
Non-Insured Health Benefit Description: The first
lab procedure code if lab costs are associated with the claimed
professional procedure
Code: F34
Field Name: Lab Procedure Code # 1
Non-Insured Health Benefit Description: The dollar
amount claimed for the first lab procedure code, if applicable.
Code: F35
Field Name: Lab Procedure
Non-Insured Health Benefit Description: Code #
2
The second lab procedure code associated with the claimed professional
procedure, if applicable. May not be available as an input field
on all dental office software.
Code: F36
Field Name: Lab Procedure
Non-Insured Health Benefit Description: Fee #
2
The dollar amount claimed for the second lab procedure code, if
applicable. If lab procedure code # 1 and lab procedure code #
2 are entered on the claim submission, they are added together
for lab fee adjudication purposes and the lab fee allowed is returned
as the amount allowed for lab procedure fee # 1.
Manual Claim Submissions Required Data Elements
FCH and FNIHB Regional Offices accept these forms for manual claim
and predetermination submissions:
- Standard Dental Claim Form;
- Computer generated form;
- ACDQ Dental Claim and Treatment Plan Form; and
- NIHB Dent -29 form.
All mandatory data elements (for example supporting documents,
tooth charting, client identification, or band number and family
number, 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; and
- Claims payable to a third party.
Do not combine different types of requests on a single claim form.
A claim form can only be submitted for a post approval, predetermination,
claim submission or a client reimbursement.
These data elements are required for post approvals, predeterminations,
claim submissions, and client reimbursements. The field names in
the left column correspond to fields on the NIHB DENT-29 form.
Shaded Sections of the NIHB DENT-29 form are reserved for use by
FNIHB Regional Offices. The these data elements must also be included
on the claim form if a Standard Dental Claim form, a computer generated
form, or ACDQ Dental Claim and Treatment Plan Form is used.
NIHB Required Data Elements
For Post Approval - To indicate if the submission
is for a post approval request.
For Predetermination - To indicate if the submission
is for a predetermination request.
For Claim - To indicate if the submission is
for a claim.
Claim Information (Provider to Complete) Field Names and
Descriptions:
- Client Surname - The surname under which the
client is registered as an NIHB client.
- Given Names - The given names under which
the client is registered as an NIHB client. Submission of more
than one given name is preferred to facilitate client verification.
Initials are not acceptable.
- Address - The complete address of client.
Submissions that do not indicate the complete client address
including postal code are rejected.
- Provider No. - If applicable, the full unique
9-digit provider number assigned to the dental practitioner by
FCH must appear on the claim form. Submissions that do not indicate
the complete FCH provider number may be rejected.
- Provider Address - A stamp with the provider
address is acceptable. The provider address must appear on the
claim form, if applicable. Submissions that do not indicate the
complete provider address may be rejected.
- For Provider Use Only - Additional information
pertaining to the submission may be noted here.
- Pay Client / Guardian - This box is checked
when the payee is other than the provider.
- Payee Address - This information must be provided
if the payee address is different from the client address or
when the client is under the age of consent.
- Office Verification/Signature Of Provider - An
original provider signature or provider name stamp is acceptable.
The signature or stamp must be that of the provider who has performed
or will perform the procedure, and must match the dental practitioner's
unique provider number indicated on a claim form.
- Date Of Service - The date on which services
were provided to the client in day/month/year format (for example,
13/07/1999 represents 13 July 1999). For procedures requiring
more than one appointment, where an insertion is required, the
date of service must be the date when the service wasinserted.
Contact your FNIHB Regional Office if insertion cannot occur.
For procedures requiring more than one appointment that do not
require an insertion, the date of service must be the date when
the service was completed.
- Procedure Code - The procedure code corresponding
to the applicable procedure.
- Int. Tooth Code - The international tooth
number, quadrant, sextant or arch code corresponding to the procedure
for which tooth number, quadrant, sextant or arch description
is mandatory.
- Tooth Surfaces - The surface code corresponding
to a procedure for which surface description is mandatory.
- Professional Fee - The dollar amount claimed
for professional services.
- Laboratory Fee - The dollar amount charged
for lab work. An original invoice or photocopy must be attached
to the claim.
- Total Fee - The total dollar amount charged
for the procedure or service performed (professional fee + laboratory
fee).
- Predetermination / Pre-verification No. - For
a claim that has been predetermined and approved in part or in
full, the predetermination number indicated on the FNIHB confirmation
letter must be entered beside the corresponding claim line.
For a claim for pre-verified services, the pre-verification number
(V-prefixed number) must be entered beside the corresponding
claim line.
A claim form may be used to claim for both predetermined and
pre-verified services, provided the appropriate authorizing numbers
are indicated beside the corresponding procedure codes.
- FNIHB Approved (To Be Completed By FNIHB) - When
FNIHB has reviewed a request for predetermination:
- YES = predetermination has been granted
- NO = predetermination has been denied
- N/A = procedure does not require predetermination
- AC = internal FNIHB code
- Total Fee Submitted - This is the sum total
dollar amount of all procedures submitted.
Client Information (Provider to Complete) Field Names
and Descriptions:
- Client Identification No. - The unique number
used to identify a client who is eligible to receive benefits
under the NIHB Program.
- Band No. - The 3-digit band number is only
applicable to First Nations clients.
- Family No. - The 4 or 5-digit family number
is only applicable to First Nations clients.
- Date Of Birth - The client's full birth date
in day-month-year format (for example, 13/05/1992 represents
13 May 1992).
Additional Information (Provider To Complete) Field Names
and Descriptions:
- A. Are Any Dental Benefits Or Services Provided Under
Any Other Group Insurance Or Dental Plan, Workmen Compensation
Board, Government Plan Or If A Result Of An Accident, A Motor
Vehicle Or Accident Insurance Plan ? - The answers
are mandatory on all submissions.
- B. Are There Any Missing Teeth? - The answers
are mandatory on all predetermination and post approval submissions.
Predetermination Information (FNIHB To Complete) Field
Names and Descriptions
- Approved/Not Approved - The submission is
approved or not approved.
- FNIHB Authorizing Officer - FNIHB checks
the CR box if it is a Client Reimbursement and enters the authorizing
officer number, date and signature.
- No. - The pre-printed document number (composed
of an alpha prefix followed by eight digits) is the document
number which also appears on the NIHB Dental Claim Statement
(doc no.).
This number may also serve as the predetermination/post approval
number when the NIHB DENT-29 form is submitted to FNIHB as a
predetermination/post approval request.
Non-Insured Health Benefits Dental Claim Statement
The NIHB Dental Claim Statement accompanies the claims payment
cheque or electronic funds transfer notice and provides information
about each claim processed either electronically or manually. The
statement may also provide additional client identification information.
If additional client information is provided, it must be added
to the provider's records and used on all future claim submissions.
Providers must allow FCH to reverse a claim paid in error, subject
to appeal. If not possible, providers must issue a cheque payable
to FCH within a negotiated timeframe. FCH reserves the right to
withhold future payments to providers, pending receipt of monies
found paid in error. Providers may contact the Non-Insured
Health Benefits Toll-Free Inquiry Centre to clarify or appeal
the payment error reversal.
NIHB Dental Claims Statements are issued twice a month in either
French or English depending on the provider's language of choice.
EDI Claim Submissions - Dental Claim Statement
The NIHB Dental Claim Statement generated with the EDI system
includes all electronic claims which were adjudicated during the
current period, as indicated to the provider on the Explanation
of Benefits. Claims which were not adjudicated in real-time due
to a manual submission requirement or missing/invalid data as well
as claims which have been reversed do not appear on the NIHB Dental
Claims Statement generated with the EDI system.
Manual Claim Submissions -Dental Claim Statement
The NIHB Dental Claim Statement generated for manual submissions
includes all manually submitted claims which were adjudicated and
settled during the current period: paid, reduced, rejected, suspended,
adjusted (settled suspensions and reversals); it also includes
all suspended claims entered in a previous reporting period and
not yet settled.
Non-Insured Health Benefits Dental Claim Statement Messages and
Explanations
During the adjudication of dental claims, the NIHB claims processing
system may assign three-character reject and warning codes along
with messages in order to explain to providers the outcome of the
claim adjudication. A reject code, composed of an "R" followed
by two numeric characters and a corresponding text message, explains
why the claim was rejected. A warning code, composed of a "W" followed
by two numeric characters and a corresponding text message, explains
that the claim was adjudicated with modifications.
For claims submitted using the EDI system, the NIHB messages are
displayed on the Explanation of Benefit (EOB) and printed on the
NIHB Dental Claim Statement. For claims submitted manually, the
NIHB messages only appear on the NIHB Dental Claim Statement.
The NIHB Dental Claim Statement may also be used to reconcile
accounts and must be referenced when making inquiries to FCH. Corrections
to claims (including reversals) must be indicated directly below
the existing information and forwarded to FCH within 60 days of
the statement date for re-adjudication of the claim. Providers
must not alter or erase the existing information. If a claim
form is used for a correction to a previously submitted claim,
then all mandatory data elements must be filled out accordingly,
and all supporting documentation (i.e., lab invoice, etc.) must
be submitted with the claim form.
These are explanations of all NIHB codes and messages that may
appear on the EOB and on the NIHB Dental Claim Statement.
List Terminology:
- Field ID
- Identifier given to the field.
- Field Name
- Text name given to the field.
- Non-Insured Health Benefit Description
- A description of what the field is used for
Code: R04
Message: This is not an eligible benefit
Explanation: The claim has not been paid because
the item is not covered under the NIHB Program.
Code: R05
Message: Claimant could not be verified
as an NIHB client
Explanation: The claim has not been paid because
the claimant could not be verified as an NIHB client. The verification
problem may be due to the fact that the claimant:
- Has not used his or her registered surname, given names or
date of birth; or
- Has made an error in specifying the client identification
number. In such cases, it may only be necessary for the claimant
to provide more accurate client identification information.
However, if the claimant has not registered as an NIHB client,
it is necessary for the claimant to do so before service can
be provided. Contact the FNIHB Regional Office (see Directory insert).
Code: R06
Message: Client is not eligible for this
benefit
Explanation: The claim has not been paid because
the claimed procedure code is not covered under the NIHB Program
due to the age of the claimant.
Code: R07
Message: This is a duplicate claim
Explanation: The claim has not been paid because
it is a duplicate of a previously paid claim.
Code: R10
Message: Invalid provider no.
Explanation: The claim has not been paid because
the provider cannot be validated as a registered NIHB provider.
Code: R11
Message: Invalid dental office number
Explanation: The claim has not been paid because
the "Provider Office Number" cannot be validated against
the CDA Provider Number. Check the claim and re-submit with the
corrected information.
Code: R12
Message: Insufficient client information
to adjudicate claim
Explanation: The claim has not been paid because
it did not provide sufficient information to determine if the claimant
is an NIHB client. To facilitate client verification, this client
information must be provided for each claim:
- Surname.
- Given Names.
- Date of Birth.
- Client Identification Number.
Check the claim for missing or incomplete information and provide
the required information to FCH.
Code: R14
Message: Insufficient benefit information
to adjudicate claim
Explanation: The claim has not been paid because
it did not provide sufficient information to determine if the claimed
procedure is eligible under the NIHB Program. At a minimum, this
information must be provided on each claim:
- Date of Service.
- Procedure Code.
- Professional Fee.
Check the claim for missing or incomplete information and provide
the required information to FCH.
Code: R20
Message: Submit claim to provincial/
territorial health plan
Explanation: The claim has not been paid because
a provincial or territorial health plan covers the procedure. Direct
the claim to the appropriate plan.
Code: R21
Message: Period for submitting claims
has expired
Explanation: The claim has not been paid because
the claim was submitted more than one year after the service was
rendered.
Code: R23
Message: Service provided prior to client's
start date
Explanation: The claim has not been paid because
the date of service is prior to the start date for the client's
NIHB coverage.
Code: R24
Message: Service provided after client's
end date
Explanation: The claim has not been paid because
the date of service is after the end date for the client's NIHB
coverage.
Code: R26
Message: Predetermination service date
violation
Explanation: The claim has not been paid because
the date of service is either before the start date or after the
end date of the predetermination approval.
Code: R27
Message: Predetermination number is invalid
Explanation: The claim has not been paid because
the predetermination number does not exist on our predetermination
database. Check the records and submit corrected information to
FCH.
Code: R28
Message: Client, provider or benefit
details on claim do not match pd letter
Explanation: The claim has not been paid because
the client, provider or benefit details on the claim do not match
those on the confirmation letter. If an error was made, supply
the corrected information to FCH. If the predetermination requires
amendment, contact the appropriate FNIHB Regional Office.
Code: R30
Message: Client has alternative coverage.
Contact FNIHB
Explanation: The claim has not been paid because
FNIHB records indicate that the client has alternative coverage
for the claimed procedure code. Contact the FNIHB Regional Office
for direction on where to submit the claim. See Directory insert
for the phone number and address of the FNIHB Regional Office.
Code: R31
Message: Client has alternative coverage.
Contact FCH
Explanation: The claim has not been paid because
FCH's records indicate that the client has alternative coverage
for the claimed procedure code. Contact FCH for direction on where
to submit the claim.
Code: R32
Message: Client has alternative coverage.
Contact FCH then submit manually
Explanation: The claim has not been paid because
FCH's records indicate that the client has alternative coverage
for the claimed procedure code. Contact FCH for direction on where
to submit the claim. When a third party payer has not reimbursed
the full amount, a manual claim may subsequently be submitted to
NIHB (refer to Coordination
with Other Health Care Plans).
Code: R35
Message: Tooth condition conflicts with
previous claim
Explanation: The claim has not been paid because
the claimed procedure code conflicts with the tooth condition on
an earlier date of service. Examples of conflicts include:
- A claim for an extraction, filling, pit/fissure sealant, crown,
posts and cores, abutment, root canal therapy or sedative dressing
when an extraction has been performed on the same tooth;
- A claim for space maintainer when a complete denture has been
performed in the same arch.
Code: R36
Message: Tooth condition conflicts with
subsequent claim
Explanation: The claim has not been paid because
the indicated procedure conflicts with the tooth condition on a
later date of service. For example, a claim for an extraction is
not paid when a claim for a filling, pit/fissure sealant, root
canal therapy, sedative dressing, abutment or crown and post and
core has already been processed with a later date of service.
Code: R37
Message: Incorrect procedure code used
Explanation: The claim has not been paid because
the procedure conflicts with another paid procedure performed on
the same date of service (e.g., inhalation anaesthesia was claimed
in combination with intravenous sedation) or the procedure does
not match the number of surfaces claimed.
Code: R38
Message: Missing or invalid tooth, surface,
arch, quadrant or sextant code
Explanation: The claim has not been paid because
the tooth code, surface code, arch, sextant or quadrant code is
missing or invalid. Check the claim for missing or incomplete information
and provide the required information to FCH.
Code: R39
Message: Invalid procedure code
Explanation: The claim has not been paid because
the procedure code is not valid. Check the records and provide
corrected information to FCH.
Code: R42
Message: Associated dental procedure
must be specified
Explanation: The claim has not been paid because
dental practitioners cannot submit an anaesthesia fee alone. If
applicable, claims for anaesthesia services must be accompanied
by a claim for an appropriate dental procedure performed on the
same date of service.
Code: R43
Message: Lab fee must be submitted for
specified procedure code
Explanation: The claim has not been paid because
the claimed procedure code is a service for which a laboratory
fee is applicable and may only be submitted for payment with the
laboratory fee upon insertion of the appliance.
Code: R44
Message: Lab or expense fee not allowed
for specified procedure code
Explanation: The claim has not been paid because
the claim contains a laboratory fee submitted with the claimed
procedure code for which a laboratory fee is not eligible. See
the current NIHB Regional Dental Benefit Grid to determine
which procedure codes may have associated laboratory fees. Expense
codes are not currently eligible under the NIHB Program.
Code: R45
Message: Invalid lab or expense procedure
code
Explanation: The claim has not been paid because
the claim contains an invalid lab or expense procedure code. See
the current NIHB Regional Dental Benefit Grid to
determine lab eligibility. Expense codes are not currently eligible
under the NIHB Program.
Code: R48
Message: Predetermination for this item
has been used up by previous claim
Explanation: The claim has not been paid because
the predetermination has already been used up by a previous claim.
Code: R49
Message: Benefit requires predetermination
Explanation: The claim has not been paid because
it requires predetermination from FNIHB. Predetermination procedures
are outlined in Pre-verification
and Predetermination.
Code: R50
Message: Frequency of the claim exceeds
the maximum allowed
Explanation: The claim has not been paid because
the claimed procedure code exceeds the maximum allowed as specified
in the current NIHB Regional Dental Benefit Grid.
Code: R66
Message: Date of service must be after
DOB
Explanation: The claim has not been paid because
the date of service on the claim is before the birth date of the
client, as indicated on the NIHB client eligibility file.
Code: W06
Message: Lab fee disallowed or reduced
to NIHB guidelines
Explanation: The laboratory fee has been reduced
or disallowed to conform to NIHB pricing guidelines. Refer to the
current NIHB Regional Dental Benefit Grid.
Code: W09
Message: Professional fee is reduced
to NIHB pricing guidelines
Explanation: The professional fee has been reduced
to conform to NIHB pricing guidelines. Refer to the current NIHB
Regional Dental Benefit Grid.
Code: W10
Message: This is a claim reversal
Explanation: The claim is a reversal of a previously
settled claim.
Code: W11
Message: Claim reduced to NIHB share
Explanation: The claimed procedure code is partially
covered by a provincial, territorial or third party plan. The amount
claimed is reduced to the correct NIHB share.
Code: W12
Message: Part of claim exceeds frequency
maximum and is disallowed
Explanation: The professional fee has been reduced
to the maximum allowed according to the NIHB frequency limitation
guidelines specified in the current NIHB Regional Dental Benefit
Grid.
Code: W13
Message: Please note corrected provider
no. For future claims
Explanation: The provider number submitted has
been corrected to reflect the current provider number for this
address. Note the number and use it on future claims submitted
from this office address.
Code: W14
Message: Please note corrected client
id for future claims
Explanation: The claimant was verified as an NIHB
client on the basis of the client information provided. However,
the submitted client information has been corrected to exactly
match the identifiers under which the client is registered as an
NIHB client. The corrections may include:
- Provision of the full client identification number
in cases where only the client's band number and family number
were submitted; or
- Correction of a submitted band number, family number, surname,
given names or date of birth.
Update the client's file and use the corrected client ID on future
claims to facilitate client verification.
Code: W15
Message: Alternate procedure code applied,
see NIHB schedule
Explanation: The claim has been adjudicated using
an alternate procedure code. Refer to the current NIHB Regional
Dental Benefit Grid .
Code: W17
Message: Claim adjusted to comply with
terms of predetermination
Explanation: The amount claimed is reduced to
comply with the terms of predetermination set out by FNIHB. See
the Predetermination Confirmation Letter for approved terms.
Code: W27
Message: Pre-verification for this item
has been used up by previous claim
Explanation: The pre-verification number for the
claimed procedure code has been used up by a previously paid claim.
Code: W28
Message: Pre-verification service date
violation
Explanation: The pre-verification number is invalid
because the date of service is either before the date of the issuance
of the pre-verification number or is more than six months after
the date of issuance of the pre-verification number.
Code: W29
Message: Pre-verification number is invalid
Explanation: The pre-verification number is invalid
for the specified client and benefit.
Code: W30
Message: Claim reduced from single to
additional extraction, same quadrant
Explanation: The professional fee has been reduced
to the amount allowed for an additional extraction in the same
quadrant.
Code: W31
Message: to maximum surfaces allowed
per tooth including previous claim
Explanation: More than five surfaces have been
submitted for this tooth with the same date of service (including
previous claims). The professional fee has been reduced so that
the total payment for the current and previous claims is limited
to the amount allowed for five surfaces.
Code: W32
Message: Duplicate surface on previous
claim. Payment limited to unique surfaces
Explanation: One or more of the claimed surfaces
has already been paid for the same procedure code, tooth and date
of service. The professional fee has been reduced to ensure that
the total payment for the current and previous claim is limited
to the number of unique surfaces. For example, if for the same
procedure code and tooth, surfaces MO have been paid and surfaces
OD are claimed, the professional fee allowed is reduced so that
the total payment for the current and previous claims is limited
to the amount allowed for the 3 unique surfaces.
Code: W82
Message: Client has not provided consent
Explanation: The NIHB Program has not been provided
with a signed Consent Form from this client.
Code: W99
Message: This claim is in suspense
Explanation: The claim requires additional investigation
before it can be fully adjudicated and continues to print on future
statements with a W99 message until it has been settled. No action
is required at this time. The adjudication result appears on a
future statement.
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