Questions and Answers - July 2005 Dental Benefits Changes
On July 1, 2005 administrative changes were introduced by Health
Canada's Non-Insured Health Benefits (NIHB) Program to make
it easier for patients to access dental benefits and reduce the
amount of administration required from dental providers to process
these benefits.
Health Canada's NIHB Program funds dental treatments necessary
to improve and maintain the oral health of eligible First Nations
people and Inuit. No deductibles or co-payments are required and
the funding of dental services is determined on an individual basis,
taking into consideration criteria such as the recipient's
oral heath status. The NIHB Program covers most dental procedures
that treat disease or the consequences of dental disease. Cosmetic
and some newer treatments with unproven results or limited clinical
success rates are not funded.
What changes were introduced on July 1, 2005 to dental
benefits and how will they improve the services being offered?
Three main changes have been introduced. These changes have been
implemented to streamline administration and simplify the Electronic
Data Interchange (EDI) claims submission process.
- Before the July 2005 administrative changes, if the cost of
a dental treatment was over $800, dental providers would need
to acquire prior approval or 'predetermination' in
order to carry out that service. Now, this $800 threshold has
been removed and dental providers no longer need to apply to
the NIHB Program, and wait for, approval to proceed with procedures
costing over $800.
- Providers can now simply supply the information required to
process a claim using the following accepted forms: the Standard
Dental Claim Form, the Association des chirurgiens dentistes
du Québec (ACDQ), and computer generated forms.
- Certain benefits, for example root canal treatment on anterior
teeth, no longer require predetermination and can be billed directly
to First Canadian Health (FCH) for payment.
Are these changes intended to help NIHB recipients or
dental providers?
Both recipients and dental providers will benefit from the changes.
For dentists and other providers who participate in the NIHB Program,
the changes will mean less paperwork and less administration. For
patients it may also provide better access to care by reducing
the waiting time for treatment.
Have dentists and dental providers been informed of these
changes?
Yes. The June 2005 and October 2005 editions of the Non-Insured
Health Benefits Dental Bulletin, which is distributed to
dental providers, contain information about the new changes.
Are there still dental services that will need predetermination
before they can be carried out?
Yes. Some services will still need predetermination. These Services
are listed in Schedule B of the Regional Dental Benefit Grid.
Why is predetermination for these dental services still
necessary?
Predetermination, or prior approval, is common to most public
and private dental plans. It is necessary because, as a public
health program, dental treatment funded by NIHB is health-based,
or targeted at conditions that directly impact health. Therefore,
recipients must meet the clinical criteria and guidelines established
by the Program for their dental treatment to be funded.
For more information, contact
a Non-Insured Health Benefits Regional Office.
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