Sample Predetermination Confirmation Letter
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Sample Predetermination Confirmation Letter
The letter includes:
- Full address of the First Nations and Inuit Health Branch (FNIHB)
Regional Office;
- Settled date of the predetermination;
- Full name and address of the dental practitioner who has requested
predetermination (the predetermination is granted only to the dental
practitioner to whom the confirmation letter is addressed);
- Salutation;
- Verified client identification information (Client ID, Surname,
Given Name, Band Number, Family Number and Date of Birth);
- Provider Number;
- Predetermination Number;
- Procedure Code;
- Tooth Code, if applicable (including quadrant, sextant or arch);
- Tooth Surface, if applicable;
- Start Date of the predetermination;
- End Date of the predetermination;
- Professional Fee;
- Maximum Dollar Amount Approved;
- Laboratory Fee, if applicable;
- A "+L" beside the MAXIMUM AMOUNT APPROVED ($) field indicates
that a lab fee has been approved in addition to the indicated
maximum amount approved;
- If "+L" is not displayed and lab fees normally apply to the procedure,
the maximum professional amount approved includes both
professional and any laboratory fee allowed under the NIHB Program.
- Fixed prosthetics message if applicable; AND
- Fixed prosthetics plan approved as an alternate benefit to allowed
$ maximum including lab, apportioned as indicated.
- General Comments.
- Reminder; The predetermination number and provider number must be
quoted on your claim.
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