Dental Benefits Guide: Non-Insured Health Benefits Program

July 30, 2018

This guide provides information on the Indigenous Services Canada Non-Insured Health Benefits (NIHB) Program and its policies relevant to dental providers and clients. It explains the extent and limitations of the NIHB Program's dental benefits by describing the important elements of each associated policy. It also lists website addresses to provide dental providers and clients quick access to related forms and more detailed Program information.

Refer to the Dental Claims Submission Kit available at Express Scripts Canada for the process to submit claims for payment of services rendered to eligible clients.

Table of Contents

1.0 Introduction

The NIHB Program provides eligible First Nations and Inuit with coverage for a range of medically necessary health benefits when these benefits are not otherwise covered through private or provincial/territorial health insurance plans or social programs.

The benefits provided under the NIHB Program include prescription drugs, dental care, vision care, medical supplies and equipment, mental health counselling, and medical transportation to access medical services not available on-reserve or in the community of residence.

1.1. NIHB Program Dental Benefits

The NIHB Program's dental benefit covers dental services including diagnostic, preventive, restorative, endodontic, periodontal, prosthodontic, oral surgery, orthodontic and adjunctive services.

The individual services are listed in the NIHB Regional Dental Benefit Grids and are based on the Canadian Dental Association (CDA) Uniform System of Coding & List of Services, Association des chirurgiens dentistes du Québec (ACDQ) Fee Guide, Fédération des dentistes spécialistes du Québec (FDSQ) Fee Guide, Denturist Association of Canada (DAC) Procedure Codes Master List, and Canadian Dental Hygienists Association (CDHA) National List of Service Codes.

Terms and conditions for coverage are detailed in section 3.0.

1.2. Purpose of the Guide

The Dental Benefits Guide summarizes the terms and conditions, criteria, guidelines and policies under which the NIHB Program covers dental services for eligible First Nations and Inuit clients.

As policies and procedures evolve, the guide is updated accordingly and dental providers are advised of these changes through the Program's newsletters and other communication tools (such as fax broadcasts).

Dental providers are advised to read and retain the most current version of the guide to ensure continued compliance with their NIHB provider enrollment. In the event of a contradiction between document versions, the provisions of the Indigenous Services Canada web-posted guide, along with the latest NIHB dental publications and regional dental grids, will prevail.

2.0 General Principles

2.1 The NIHB Dental Benefits Guide applies to the coverage of dental benefits by the NIHB Dental Predetermination Centre or by First Nations or Inuit Health Authorities or organizations (including territorial governments) who, under a contribution agreement, have assumed responsibility for the administration and coverage of dental benefits to eligible clients.

2.2 Dental benefits are covered in accordance with the mandate of the NIHB Program. NIHB clients do not pay deductibles or co-payments. The NIHB Program encourages dental providers to bill the Program directly and not to balance-bill clients so that clients do not face charges at the point of service.

2.3 The NIHB Program provides benefits based on policies established to provide eligible clients with access to benefits not otherwise available under federal, provincial, territorial or private health plans.

2.4 The NIHB Program covers most dental procedures that treat dental disease or the consequences of dental disease.

2.5 Coverage of dental services is determined on an individual basis taking into consideration criteria such as the client's oral health status.

2.6 The NIHB Program will consider coverage beyond its frequency limitations for eligible dental services required as a result of trauma, as long as the client's condition meets the established policies, guidelines and criteria.

2.7 Certain dental services are not covered under the NIHB Program (e.g. extensive rehabilitation and cosmetic treatment). These services are defined as exclusions and cannot be considered for appeal.

2.8 Consistent with the NIHB Program policies for all benefits, the Program does not cover any dental procedures related to non-eligible dental services, nor does it cover dental procedures related to a dental service reviewed by the Program where it did not meet the established policies, guidelines and criteria.

2.9 Dental benefits must be provided by a NIHB recognized dental provider such as a dentist, dental specialist, independent dental hygienist, or denturist, who is licensed, authorized, and in good standing with the regulatory body of the province/territory in which they practice. They may provide eligible clients with medically necessary NIHB eligible dental services, provided that the services are rendered within NIHB Program policies, guidelines and criteria, frequency limitations and predetermination requirements.

2.10 When claiming for services, it is the dental provider's responsibility to:

  1. verify the eligibility of the client;
  2. ensure that no limitations will be exceeded; and
  3. ensure compliance with NIHB coverage criteria, guidelines and policies.

3.0 Terms and Conditions

To be eligible for payment of services rendered, dental providers must adhere to the terms and conditions of the NIHB Program. These are detailed within in the Dental Claims Submission Kit, including the procedures for verifying client eligibility and submitting NIHB benefit claims.

Dental providers are to assist NIHB clients in completing and submitting claim forms for client reimbursements. All mandatory data elements, tooth charting & number, procedure code, date of service (DOS), client identification, client address, band number and/or family number and date of birth), must be completed on claim forms; supporting documentation must be attached. Provider and client (parent/legal guardian) signatures are mandatory.

4.0 Payment and Reimbursement

Dental providers are encouraged to enroll with the NIHB Program and to send their claims directly to Express Scripts Canada so that clients do not pay fees at the point of service. For some clients, balance billing and charging up front for services are barriers to accessing medically necessary dental services.

All claims must be received by the NIHB Program within one (1) year from the date of service to be eligible for payment or reimbursement. The service must be an eligible benefit under the NIHB Program as of the date of service, and all policies and requirements for coverage apply.

This policy applies to payments to NIHB enrolled providers for services rendered, and reimbursements to clients who have paid fees directly to an NIHB-recognized provider for eligible services.

Note:

  • The one (1) year policy applies to the initial claim submission and includes all subsequent resubmissions following a rejection under NIHB (e.g. missing required data elements; incorrect procedure code used, client has alternative coverage, etc.).
  • The coordination of benefits with other plans must also be completed within one (1) year from the date of service.

Claims older than one (1) year from the date of service are not eligible for payment or client reimbursement and therefore will not be accepted for processing.

All requests for client reimbursement of eligible benefits must include:

  • Original receipt(s) for proof of payment;
  • NIHB Client Reimbursement Request Form completed and signed; and
  • ONE of the following:
    • Association des Chirurgiens Dentistes du Québec (ACDQ) Dental Claim and Treatment Plan Form;
    • Standard Dental Claim Form; or
    • Canadian Association of Orthodontics Information Form.

OR

  • Original receipt(s) for proof of payment; and
  • NIHB Dental Claim Form (Dent-29) completed and signed.

If applicable, a detailed statement or Explanation of Benefits (EOB) from all other health plan(s)/program(s) must be provided.

Note: Credit card/debit (Interac) slips are not acceptable forms for proof of payment of original receipts. Original receipts are not required when they have been submitted first to the NIHB client's other health plan(s)/ program(s), and the detailed statement or EOB from them is attached along with a copy of the original receipt.

Quick Link

4.1. Coordination of Benefits

Clients are required to access any public or private health or provincial/territorial programs for which they are eligible prior to accessing the NIHB Program. When an NIHB-eligible client is also covered by another public or private health care plan, claims must be submitted to the client's other health care or benefits plan first. The other payer will provide an EOB form that must be sent to the NIHB Program. The NIHB Program will then coordinate payment with the other payer on eligible benefits.

Where a client is no longer eligible for coverage from another payer, the provider can contact Express Scripts Canada or the client can contact the Dental Predetermination Centre to update the file.

4.2. Laboratory Fee Submission

Certain dental services require laboratory work. Laboratory fee submissions will be considered for coverage under the NIHB Program only in conjunction with an approved procedure code. However, the NIHB Program reserves the right to require a copy of the laboratory report and to adjust the laboratory fee requested by dental providers.

5.0 Privacy

As a federal government Program, the NIHB Program has the responsibility to protect personal information under their control in accordance with the Privacy Act and its related Treasury Board privacy policy and directives, and is also responsible for ensuring that the personal information collected is limited to that which is necessary to administer the Program.

For more information on applicable privacy practices, please contact the Department's Privacy Management Division.

6.0 Definitions

Exceptions: These are dental procedures that are outside the NIHB Program scope of benefits or procedures that require special consideration. Requests must be supported with a rationale and predetermination is mandatory.

Exclusions: These are dental procedures that are outside the mandate of the NIHB Program and will not be considered for coverage nor considered for appeal, e.g. fixed prosthodontics, porcelain/ceramic crowns, implants and all implant related procedures, veneers, cosmetic services, ridge augmentation, and appliances to treat bruxism and snoring/sleep apnea.

Frequency Limitation: Limitations put against procedure codes so maximums are not exceeded, as specified in the current NIHB Regional Dental Benefit Grids and in the present Dental Benefits Guide.

Predetermination (PD): Predetermination is a method for the administration and adjudication of dental benefits. Predetermination is seeking review prior to proceeding with treatment and enables both the dental provider and client to understand the benefit coverage commitments.

Post-determination: Post-determination is a method for the administration and adjudication of dental benefits for service which has been rendered. This is a submission that will be considered for coverage under specific circumstances under the NIHB Program and must be supported with a rationale.

Appeal Process: This is a client (parent/guardian)-initiated process seeking reconsideration of a denied request under the NIHB Program. Note that exclusions are not considered for appeal.

NIHB Dental Provider: A licensed dental professional who is authorized and in good standing with the regulatory body in the province or territory in which they practice and who is enrolled with the NIHB Program.

Current Radiograph: Radiographs that are dated within one year (i.e. within the last twelve months) of the submission.

7.0 Submission Requirements

The NIHB Program requires the following standard documentation and information for the review of any predetermination and post-determination request:

  • Predetermination/post-determination request on one of the following forms: Standard Dental Claim Form, ACDQ Dental Claim and Treatment Form, computer generated form, CDHA National Dental Hygiene Claim Form, or NIHB Dental Claim Form (Dent-29)
  • Comprehensive treatment plan from the treating and/or referring dentist/specialist, indicating all completed treatments and pending treatment needs, including restorative, periodontal, prosthodontic, endodontic, orthodontic and surgical services
  • Current conventional or digital radiographs (within last twelve months):
    1. Periapical and bitewing radiographs:
      • must be of good diagnostic quality (i.e., size, resolution, contrast); and
      • must be mounted and labelled with the date of service, client name and provider name.
    2. A panoramic radiograph may be submitted in addition to, but not in place of bitewing and periapical radiographs.

      Note: if duplicate radiographs are submitted they must identify the right or left side of the client's mouth.

      When submitting enlarged digital radiographs, of any type, dental providers are requested to print a measurement scale on the radiographs to facilitate the assessment.
  • Notation of all missing teeth
  • Periodontal charting, and/or Periodontal Screening and Recording (PSR), and/or Periodontal assessment
  • Periodontal tooth specific measurements (6 sites/tooth), where applicable (Refer to the appropriate policy in this guide)
  • All pertinent clinical findings/notes supporting the predetermination request
  • At NIHB's request, other documentation may be required

Note: It is mandatory for dental providers to maintain a client chart/record documenting and supporting the services provided, claimed, and paid for by the NIHB Program. A procedure code and/or name of services rendered are not sufficient in a client chart/record to adequately support the validation of a payment. This statement applies to all claim requests under the NIHB Program.

8.0 NIHB Dental Procedures

8.1. Diagnostic Services

8.1.1. Examinations

Clients under seventeen (17) years of age are eligible for up to four (4) examinations and those seventeen (17) and older are eligible for up to three (3) examinations in any twelve (12) month period provided these examinations are within their frequency limitations and carried out by legally licensed dental professionals.

These examinations can include:

  • Examination and diagnosis complete
  • Examination and diagnosis limited, new patient
  • Examination and diagnosis recall
  • Examination and diagnosis specific
  • Examination and diagnosis emergency

Frequency limitations take into account overall interactions between various examination services rendered by the same provider, different providers within the same office or different offices, as well as the eligibility period for each service.

Examinations performed by dental specialists and denturists do not count against the maximum number of eligible annual examinations.

Frequency Guidelines for Examinations
Dental Procedure Frequency Guidelines
Complete Oral Examination and Diagnosis 1 in any 60 months

When a Complete Examination is provided, it replaces the When a Complete Examination is provided, it replaces the Recall Examination and the New Patient Limited Examination for the respective eligible period.
New Patient Limited 1 in a lifetime, with same provider or different provider in the same office

in any 12 months, with different provider in a different office
Recall Examination Age 17+: 1 in any 12 months

Under age 17: 1 in any 6 months
Specific Examination 1 in any 12 months
Emergency Examinations 1 in any 12 months
Specialist Examinations and Diagnosis - Complete (require PD) 1 in any 60 months per specialty (with GP referral and justification for the referral)

When a Specialist Complete Examination is adjudicated, it eliminates Specialist Limited Examination within the same specialty in that twelve (12) month period.
Specialist Examination and Diagnosis - Limited 1 in any 12 months/ specialty (with GP referral and justification for the referral)

8.1.2. Radiographs

All radiographs submitted with a treatment plan must be current, mounted, dated with the date of service, and of good diagnostic quality. Both dental provider and client names must be indicated on the mount. Whenever duplicate radiographs are submitted, the dental provider must indicate on the radiograph whether the radiograph is on the right or left side of the client's mouth.

When submitting enlarged digital radiographs, of any type, dental providers are requested to print a measurement scale on the radiograph to facilitate the assessment.

Radiographs are considered "current" for predetermination purposes if dated within one year of the PD submission.

Frequency Guidelines for Radiographs
Dental Procedure Frequency Guidelines
Intraoral Periapical Radiographs (11-15 films), Complete Serie 1 in any 60 months

Not to be covered in conjunction with a panoramic radiograph for the time period (60 months)
Intraoral Radiographs (1-10 films) (includes periapical, bitewing and occlusal radiographs) 10 in any 12 months
Panoramic Radiographs 1 in any 60 months; up to 3 in a lifetime

Not to be covered in conjunction with periapical radiographs (11-15 films) or a complete series for the time period (60 months)

Any combination of intraoral radiographs (periapicals, bitewings and occlusal) exceeding 10 films, are not to be covered in conjunction with a panoramic radiograph for the time period (60-months), and vice versa.

8.1.3. Laboratory tests, analysis

When submitting requests for coverage of laboratory tests/analysis, a copy of the laboratory report is required.

8.2. Preventive Services

For preventive services including polishing, scaling, fluoride treatments, pit and fissure sealants/preventive restorative resin services, please refer to the Preventive and Periodontal Policy in section 8.5 Periodontal Services.

Frequency Guidelines for Interproximal Disking of Teeth
Dental Procedure Frequency Guidelines
Interproximal Disking of Teeth (requires PD) 1 unit in any 12 months.

8.3. Restorative Services

Repeat restorations/extensions for the same tooth performed by the same provider or different provider in the same office, excluding a core or crown, within a two (2) year time frame is subject to audit and requires a written rationale documented in the clients chart on date of service delivery.

Restorations for incisal wear; involving enamel, dentin or enamel and dentin are considered cosmetic/aesthetic services (exclusions) under the NIHB Program and therefore will not be considered for payment.

8.3.1. Restorations, Primary Teeth

Requirements for restoration of primary incisors teeth 51, 52, 61, 62, 71, 72, 81, 82:

  • clients must be under the age of five
  • tooth is eligible once (1) in any 12-month period by the same provider, or different provider in the same office
  • no combination of procedure codes/surfaces/classes involving, or not, distinct claim lines for the same tooth, should exceed in one visit the cost applicable to the collective number of procedure code/surfaces/classes restored, up to a maximum cost of a polycarbonate crown (the lesser amount to be paid)
  • when both composite and amalgam procedure codes are billed on the same tooth, the system will pay the cost of the lesser amount up to a maximum cost of a polycarbonate crown (the lesser amount to be paid)
  • bonded amalgams are covered at the rate of a non-bonded equivalent

Requirements for restoration of primary teeth 53, 54, 55, 63, 64, 65, 73, 74, 75, 83, 84, 85:

  • tooth is eligible once (1) in any 12-month period by the same provider, or different provider in the same office
  • no combination of procedure codes/surfaces/classes involving, or not, distinct claim lines for the same tooth, should exceed in one visit the cost applicable to the collective number of procedure code/surfaces/classes restored, up to a maximum cost of a stainless steel crown (SS) (the lesser amount to be paid)
  • when both composite and amalgam procedure codes are billed on the same tooth, the system will pay the cost of the lesser amount up to a maximum cost of a SS crown (the lesser amount to be paid)
  • bonded amalgams are covered at the rate of a non-bonded equivalent

8.3.2. Restorations, Permanent Teeth

Requirements for restoration of permanent anterior and posterior teeth:

  • tooth is eligible once (1) in any 12-month period by the same provider, or different provider in the same office
  • no combination of procedure codes/surfaces/classes involving, or not, distinct claim lines for the same tooth, should exceed in one visit the cost applicable to the collective number of distinct surfaces restored, up to a maximum cost of a five surface restoration/complete tooth reconstruction (the lesser amount to be paid)
  • when both composite and amalgam procedure codes are billed on the same tooth, the system will pay the cost of the lesser amount up to a maximum cost of an amalgam five surface restoration/complete tooth reconstruction (the lesser amount to be paid)
  • bonded amalgams are covered at a rate of a non-bonded equivalent

8.3.3. Caries, Trauma and Pain Control

Caries, trauma and pain control procedures will not be considered for coverage in conjunction with any of the following procedures: restorations, open and drain, pulpectomy, pulpotomy or root canal, if requested for the same date of service and for the same tooth.

Frequency Guidelines for Caries, Trauma and Pain Control
Dental Procedure Frequency Guidelines
Caries, Trauma and Pain Control Maximum 2 teeth in a lifetime, as an emergency

8.3.4. Cores and Posts

Cores are eligible only if the existing restoration is greater than twelve (12) months old, and will be considered for coverage only in conjunction with an approved predetermination crown request.

Bonded amalgam cores are covered at a rate of a non-bonded equivalent.

A prefabricated post/pin is eligible only when inadequate coronal tooth structure is remaining to retain a restoration.

Prefabricated posts in combination with core, including pin(s) where applicable, will be considered for coverage only in conjunction with an approved predetermination crown request. When a prefabricated post, pin(s), and a core procedure codes are requested individually for the same tooth for a crown, the Program will adjust the fee at the rate of the combination procedure code.

Cores, and prefabricated posts in combination with cores, are eligible only for clients 18 years of age and older.

Frequency Guidelines for Cores and Posts
Dental Procedure Frequency Guidelines
Cores and Posts (require PD) 4 in any 10 years per client (permanent teeth only)
Post Removal 1 in a lifetime, per permanent tooth

8.3.5. Crowns

Crown Policy

8.3.5.1. General Principles

The general principles of the crown policy are as follows:

  • the Non-Insured Health Benefits Program (NIHB) will consider coverage for a crown when both the eligibility and restorability criteria have been met
  • all crowns require predetermination
  • there is a frequency limitation of four (4 ) crowns in any 10 year period per client
  • only single unit metal or porcelain-fused to metal crowns are eligible under the NIHB Program
  • porcelain/ceramic crowns, including fortified/reinforced porcelain/ceramic crowns, are not a covered benefit under the NIHB Program (exclusions)
  • all basic treatment addressing any existing active biological disease (caries and periodontal), must be completed before submitting requests for crowns
  • the NIHB Program will not consider coverage for a crown in the following circumstances:
    • to improve aesthetics
    • to treat sensitivity due to cracked tooth syndrome, erosion, abrasion or attrition
    • to treat stress fractures or chipping on teeth that have a minimal restoration or no restoration
    • for high caries risk individuals or those with generalized moderate to severe periodontal disease when there is evidence of long-standing, uncontrolled and/or untreated rampant biological disease (either caries or periodontal disease)
8.3.5.2. Predetermination Documentation Requirements for Crowns

The NIHB Program requires the following standard documentation for the review of a crown predetermination request:

  • Predetermination requested on one of the following forms: Standard Dental Claim Form, ACDQ Dental Claim and Treatment Form, computer generated form, or NIHB Dental Claim Form (Dent-29)
  • Comprehensive treatment plan from the treating and/or referring dentist/specialist, indicating all completed treatment and pending treatment needs including restorative, periodontal, prosthodontic, endodontic, orthodontic and surgical services
  • Current conventional or digital radiographs (within last twelve months)
    1. Periapical and bitewing radiographs:
      • must be of good diagnostic quality (i.e., size, resolution, contrast); and
      • must be mounted and labelled with the date of service, client name and provider name.
    2. A postoperative periapical radiograph must be submitted for a tooth that has been endodontically treated in the last 12 months
    3. A panoramic radiograph may be submitted in addition to, but not in place of bitewing and periapical radiographs

      Note: if duplicate radiographs are submitted they must identify the right or left side of the client's mouth.

      When submitting enlarged digital radiographs, of any type, dental providers are requested to print a measurement scale on the radiograph to facilitate the assessment.

  • Photographs of tooth (teeth), if available
  • Notation of all missing teeth
  • Periodontal charting, and/or Periodontal Screening and Recording (PSR), and/or Periodontal assessment
  • Periodontal measurements (6 sites/tooth) for the tooth/teeth under review
  • All pertinent clinical findings/notes supporting the predetermination request
8.3.5.3. Tooth Eligibility

The NIHB Program will consider coverage of a single unit crown for:

  • incisors, canines, bicuspids and first molars;
  • second molars (will be considered for coverage where the first molar is missing and the second molar is in occlusion with a prosthetic or natural molar);
  • third molars (will be considered for coverage where the first and the second molars are missing and the third molar is in occlusion with a prosthetic or natural molar);
  • clients 18 years of age and older; and
  • eligible teeth, one (1) per tooth in any eight (8) year period (96 months).
8.3.5.4. Tooth Restorability

The NIHB Program will consider coverage of a single unit crown on endodontically and non-endodontically treated teeth when all of the following criteria are met:

  • Adequate periodontal support, based on alveolar bone levels (crown to root ratio of at least 1:1) visible on submitted radiographs with absence of furcation involvement;
  • Absence of active periodontal disease;
  • Adequate remaining non-diseased tooth structure to ensure that biologic width (3 mm) is maintained and adequate ferrule (1.5 mm) is achieved during restoration;
  • An extensively restored tooth where the existing tooth structure can no longer support a direct restoration. The Program defines an extensively restored tooth as follows:
    • For all anterior teeth (endodontically and non-endodontically treated): restoration/loss of tooth structure involves the entire incisal edge, from mesial to distal, and extends cervically to both interproximal contacts
    • For endodontically treated premolars and molars: restoration/loss of tooth structure involves three or more continuous surfaces and involves either both mesial and distal marginal ridges, or the entire destruction of a cusp, as demonstrated with radiographs. In addition, providers have the choice to submit photographs, if available.
    • For non-endodontically treated premolars and molars: restoration/loss of tooth structure involves five continuous surfaces
  • A mesio-distal space (vertically and horizontally) equivalent to that of the natural tooth with no loss of space due to caries or crowding;
  • A tooth that does not require any additional treatment such as crown lengthening, root re-sectioning or orthodontic treatment; and
  • Endodontically treated teeth must be proven successful as demonstrated on a postoperative periapical radiograph showing that healing has occurred.
8.3.5.5. Non-Inserted Crown Policy

The NIHB Program will consider paying up to 20% of the current NIHB professional fee and 100% of the laboratory fee, if applicable, for non-inserted crowns under the following conditions:

  • the crown has been completed but not inserted due to circumstances beyond the control of the dental provider;
  • the provider has made substantial efforts to contact the client to schedule an insertion appointment; and
  • the provider has communicated the details of the situation in writing to the NIHB Dental Predetermination Centre.

    Note: A non-inserted crown that has been claimed and paid in full, without complying with the above noted conditions, will result in recovery.
Frequency Guidelines for Crowns
Dental Procedure Frequency Guidelines
Crowns (require PD) 4 in any 10 years per client

1 per eligible tooth in any eight (8) year period (96 months)
Repair to Crowns 1 in any 36 months, per tooth
Recementation of Crowns 1 in any 36 months, per tooth

8.4 Endodontic Services

Endodontic Policy

8.4.1. General Principles

The general principles of the endodontic policy are as follows:

  • Predetermination is not required for root canal treatment (RCT) on anterior teeth, bicuspids, first and second molars; however, the NIHB Program reserves the right to request preoperative records to ensure compliance with the endodontic policy
  • Predetermination is required for RCT on third molars
  • There is a frequency limitation of three (3) RCT procedures in 36 months for all teeth; once the frequency has been reached, subsequent RCT procedures require predetermination
  • The NIHB Program will consider coverage for a RCT when both the eligibility and restorability criteria have been met and the need of the requested treatment for the health of the client is evident and supported in the documentation submitted
  • The NIHB Program will not consider coverage for a RCT for high caries risk individuals or those with generalized moderate to severe periodontal disease when there is evidence of long-standing, uncontrolled and/or untreated rampant biological disease (either caries or periodontal disease)
  • While assessing predetermination submissions for other dental services (e.g. crowns), any paid standard RCT observed in the supporting documentation provided, claimed without a PD and determined non-compliant will be subject to payment recovery
  • For recurrent non-compliant providers the NIHB Program will reinstate predetermination requirement
  • NIHB Dental Predetermination Centre (DPC) maintains the right to request supporting documentation for paid endodontic cases not supported with a predetermination, which will be reviewed against the NIHB Endodontic Policy. Cases that do not meet the endodontic policy may result in payment recovery.

8.4.2. Predetermination Documentation Requirements for Root Canal Treatment

The NIHB Program requires the following standard documentation for the review of a root canal treatment predetermination request:

  • Predetermination requested on one of the following forms: Standard Dental Claim Form, ACDQ Dental Claim and Treatment Form, computer generated form, or NIHB Dental Claim Form (Dent-29)
  • Comprehensive treatment plan from the treating and/or referring dentist /specialist indicating all completed treatment and pending treatment needs including restorative, periodontal, prosthodontic, endodontic, orthodontic and surgical services
  • Current conventional or digital radiographs (within last twelve months).
    1. Periapical and bitewing radiographs:
      • must be of good diagnostic quality (i.e., size, resolution, contrast), and
      • must be mounted and labelled with the date of service, client name and provider name.
    2. A panoramic radiograph may be submitted in addition to, but not in place of bitewing and periapical radiographs

      Note: if duplicate radiographs are submitted they must identify the right or left side of the client's mouth.

      When submitting enlarged digital radiographs, of any type, dental providers are requested to print a measurement scale on the radiograph to facilitate the assessment.

  • Notation of all missing teeth
  • Periodontal charting, and/or Periodontal Screening and Recording (PSR), and/or Periodontal assessment
  • Periodontal measurements (6 sites/tooth) for the tooth/teeth under review
  • All pertinent clinical findings/notes supporting the predetermination request

8.4.3. Tooth Eligibility

The NIHB Program will consider coverage of an RCT on:

  • incisors, canines, bicuspids, and first and second molars; and
  • third molars will be considered for coverage where the first and the second molars are missing and the third molar is in occlusion with a prosthetic or natural molar.

8.4.4. Tooth Restorability

The NIHB Program will consider coverage of an RCT when all of the following criteria are met:

  • adequate periodontal support, based on alveolar bone levels (crown to root ratio of at least 1:1) visible on submitted radiographs with absence of furcation involvement;
  • absence of active periodontal disease;
  • adequate remaining non-diseased tooth structure to ensure that biologic width (3 mm) can be maintained during restoration;
  • a mesio-distal space (vertically and horizontally) equivalent to that of the natural tooth with no loss of space due to caries or crowding; and
  • a tooth that does not require any additional dental treatment such as crown lengthening, root resectioning or orthodontic treatment.

8.4.5. Pulpectomies and Pulpotomies

  • Coverage for pulpectomy/pulpotomy is one (1) per tooth/per lifetime
  • Pulpotomies and pulpectomies are not eligible on primary incisor (teeth number 51, 52, 61, 62, 71, 72, 81 and 82)
  • Incomplete approved RCT requests will be paid to the equivalent of a pulpectomy
  • The final fee for a RCT includes the cost associated with a pulpectomy/pulpotomy and open and drain within the three month period prior to the completion of the RCT, when performed by the same provider/ same office
  • The final fee for a RCT or pulpectomy/pulpotomy includes the fee for the temporary restoration and its replacement if required
Frequency Guidelines for Root Canal Therapy
Dental Procedure

Frequency Guidelines

Root Canal Therapy

3 RCTs in any 36 months for all teeth

8.5 Periodontal Services

Preventive and Periodontal Policy

8.5.1. General Principles

The general principles on the preventive and periodontal services policy are as follows:

  • Predetermination is not required for scaling and root planing services up to the annual maximum allowable units; for any additional units, predetermination is required (refer to Table 8.5.2.1.)
  • Predetermination requests must be supported with all items listed in Section 8.5.4. Predetermination Documentation Requirements for Preventive and Periodontal Services
  • All preventive and periodontal procedures claimed must be supported with proper, clear, and detailed documentation for verification purposes as per the terms and conditions of the NIHB Program. A procedure code or procedure name in a client record is not sufficient to substantiate a claim for payment.

8.5.2. Preventive Services

8.5.2.1. Frequency Guidelines for Polishing, Fluoride Treatment, Scaling and Root Planing
Preventive Services
Age 0-11 years 12-16 years 17+ years
Recall Exam Annual Maximum Table 1 footnote * 1 in any 6 month period 1 in any 6 month period 1 in any 12 month period
Polishing Annual Maximum 1 time in any 6 month period 1 time in any 6 month period 1 time in any 12 month period

Fluoride Annual Maximum

(includes Varnish Fluoride and other Topical Fluoride eligible treatments)

1 treatment in any 6 month period 1 treatment in any 6 month period Not covered
Scaling in combination with Root Planing Annual Maximum (no PD) 1 unit in any 12 month period 2 unit in any 12 month period 4 units in any 12 month period

Table 1 footnotes

Table 1 footnote 1

Please refer to 8.1. Diagnostic Services section for frequency guidelines.

Return to table 1 footnote * referrer

8.5.2.2. Sealants and Preventive Resin Restorations
  • Clients seventeen (17) years of age and under are covered for sealants and preventive resin restorations on the occlusal surface of permanent molars (16, 26, 36, 46, 17, 27, 37, 47), bicuspids (14, 15, 24, 25, 34, 35, 44, 45); and on the lingual surface of permanent maxillary incisors (11, 12, 21, 22) , where surfaces are unrestored
  • There will be a lifetime limit of two (2) sealants/preventive resin restorations per eligible tooth.

8.5.3. Periodontal Services

8.5.3.1 Scaling and Root Planing (additional units)
  • Predetermination is required for the NIHB Program to consider coverage for additional units of scaling and root planing over the maximum allowable units covered without predetermination (refer to Table 8.5.2.1.)
  • Eligibility for additional units of scaling and root planing will be based on several factors including:
    • the severity of periodontal disease based on current (within the last 12 months) clinical notes, diagnosis and prognosis, complete periodontal charting, and radiographs;
    • comprehensive treatment plan addressing all client oral health needs;
    • the date of the last visit for periodontal and preventive services;
    • the regularity and compliance of periodontal maintenance; and
    • medical condition relative to periodontal diseases including any prescribed medication.
8.5.3.2. Surgical Services
  • Periodontal surgeries are not eligible services under the NIHB Program, however certain surgeries will be considered for coverage on an exception basis (PD required):
    • gingivoplasties/gingivectomies for the treatment of drug-induced gingival hyperplasia that is unresponsive to non-surgical periodontal therapy; and
    • gingival grafts for the treatment of gingival recession leading to minimally attached/keratinized gingiva on a tooth that is a critical abutment for a removable prosthesis.

      Note: Coverage of gingival grafts for teeth with chronic periodontal disease or performed for esthetic purposes will not be considered.

8.5.4. Predetermination Documentation Requirements for Preventive and Periodontal Services

The NIHB Program requires the following documentation for the review of a preventive/periodontal service predetermination request:

  • Predetermination requested on one of the following forms: Standard Dental Claim Form, ACDQ Dental Claim and Treatment Form, computer generated form, CDHA National Dental Hygiene Claim Form, or NIHB Dental Claim Form (Dent-29)
  • Comprehensive treatment plan from the treating and/or referring dentist/specialist, indicating all completed treatment and pending treatment needs including restorative, periodontal, prosthodontic, endodontic, orthodontic, and surgical services
  • Current conventional or digital radiographs (within the last twelve months)
    1. Periapical and bitewing radiographs:
      • must be of good diagnostic quality (e.g., size, resolution, contrast), and
      • must be mounted and labeled with the date of service, client name, and provider name
    2. A panoramic radiograph may be submitted in addition to, but not in place of bitewing and periapical radiographs

      Note: If duplicate radiographs are submitted, they must identify the right or left side of the client's mouth.

      When submitting enlarged digital radiographs, of any type, dental providers are requested to print a measurement scale on the radiograph to facilitate the assessment.
  • Periodontal charting with information regarding:
    • Missing teeth;
    • Probing depths (6 sites/tooth);
    • Recession;
    • Area of minimal attached gingiva;
    • Mobility;
    • Bleeding on probing, suppuration;
    • Plaque (generalized/localized, minimal/moderate/abundant);
    • Calculus (generalized/localized, minimal/moderate/abundant);
    • Furcation; and
    • Abscess/fistula.
  • Periodontal diagnosis and prognosis
  • All pertinent clinical findings/notes supporting the predetermination request
Frequency Guidelines for the Management of Oral Disease
Dental Procedure Frequency Guidelines
Management of Oral Disease (require PD) Eligible once (1) in any twelve (12) month period

8.6 Removable Prosthodontic Services

Partial Denture Trial Project

Starting February 19, 2018, the Non-Insured Health Benefits (NIHB) Program, in consultation with the Canadian Dental Association (CDA), the Association des chirurgiens dentistes du Québec (ACDQ), and The Denturist Association of Canada (The DAC), initiated a nationwide eight year partial denture trial project. The project will assess the merits, feasibility and appropriateness of a streamlined predetermination (PD) submission process for partial dentures under the NIHB Program’s dental benefit.

All predetermination requests under the trial project must be sent by fax to 1-833-517-0378.

General Trial Conditions:
  • Providers should read the NIHB Partial Denture Trial Project Form as it contains all the requirements under the project, including the criteria for coverage and consequence of non-compliance.
  • The trial project is open to all dentists and denturists enrolled with the NIHB Program.
  • Participation in the trial project is voluntary. Providers can decide to participate by submitting qualifying partial denture cases to the dedicated fax line. Providers who choose not to participate are to submit their partial denture cases through the regular predetermination (PD) process instead.
  • Under the trial project, NIHB will accept faxed PD submissions at the dedicated toll free number for new or replacement partial dentures meeting the frequency requirements as outlined in the NIHB Removable Prosthodontic Policy.
  • Each PD submitted under the trial project must be accompanied by a completed and signed NIHB Partial Denture Trial Project Form.
  • All other dental services requiring PD, including partial denture cases that do not meet frequency requirements, must be mailed to the Dental Predetermination Centre as per the regular PD process. Any such PD requests submitted to the trial project fax will not be processed and the provider will be notified.

Note: The Program reserves the right to make changes to the trial project and to discontinue it at any time. Providers will be informed in a timely manner of such changes.

The following table summarizes and compares the trial project submission process to the regular PD process for partial dentures under the NIHB Program:

Accepted cases under the partial denture trial project All other cases must follow the regular PD submission process
Type of cases submitted Eligible partial dentures meeting frequency requirements All other eligible services requiring PD, including partial dentures not meeting frequency requirements
PD request must be submitted by: Fax: 1-833-517-0378 Mail:   Dental Predetermination Centre
200 Eglantine Driveway
Address Locator 1902D
Ottawa, ON K1A 0K9
NIHB Partial Denture Trial Project Form Required for each case;
Fax: 1-833-517-0378
Not required
Supporting documentation Do not send documentation;
Keep it on file for the duration of the project
Mail documentation to the DPC
Periodontal criteria The periodontal criteria below will not be applied for the duration of the project The periodontal criteria below will not be applied for the duration of the project

Periodontal criteria:

“All abutment teeth must have: adequate periodontal support, based on alveolar bone levels (crown to root ratio of at least 1:1) visible on submitted radiographs; and absence of active periodontal disease”.

“If there is evidence of periodontal disease, the NIHB Program will not consider coverage for a cast partial denture. However, in such situations, the Program may consider coverage for an acrylic partial denture.”

(References from Dental Benefits Guide, section 8.6.2.)

Compliance Monitoring

During the trial project, the NIHB Program will conduct compliance monitoring with the criteria described in section A of the NIHB Partial Denture Trial Project Form, which includes the following measures:

  • Providers may be randomly selected and requested to submit to the Program supporting documentation pertaining to selected trial project cases.
  • A NIHB Partial Denture Trial Project Committee will be established to assess selected paid partial dentures against the trial criteria.
  • Failure to submit the required documentation when requested or non-compliance with the NIHB Partial Denture Trial Project criteria will result in recovery of 100% of the provider’s professional fee paid by the NIHB Program per partial denture. Where funds have been recovered, the provider cannot bill the client for these recovered amounts. Note that laboratory fees will not be subject to recovery.
  • Repeated non-compliance with the trial project criteria may result in the provider being removed from the trial project, and therefore the provider will need to submit all cases through the regular PD submission process.

Removable Prosthodontic Policy

8.6.1. General Principles

The general principles of the removable prosthodontic policy are as follows:

  • Predetermination is required for complete and partial dentures
  • Complete and partial dentures supported by implants as well as all implant related procedures are not a covered benefit under the NIHB Program (exclusions)
  • The fee for complete and partial dentures includes a three (3) month period of post-insertion care
  • Denture adjustments done on the same date of service and in conjunction with the delivery of new dentures, denture repairs, relines, rebases and/or tissue conditioning, are included in the fees billed and paid for these services
  • The fee for immediate dentures includes the tissue conditioner, but not the processed reline/rebase
  • The overall cost of replacement for a denture may be adjusted in situations where the client's history shows that claims for reline/rebase were paid within three months prior to the request

8.6.2. Removable Partial Dentures

8.6.2.1. General Principles

The general principles of removable partial dentures are as follows:

  • Removable partial acrylic dentures are covered once in any five (5) year period (60 months) per arch
  • Removable partial cast dentures are covered once in any eight (8) year period (96 months) per arch
  • Within their respective period, replacement with any type of removable denture (including complete dentures) will not be considered for coverage; however, they will be considered for modifications as per the needs of the client
8.6.2.2. Predetermination Documentation Requirements for Partial Dentures

The NIHB Program requires the following standard documentation for the review of a partial denture predetermination request:

  • Predetermination requested on one of the following forms: Standard Dental Claim Form, ACDQ Dental Claim and Treatment Form, computer generated form, or NIHB Dental Claim Form (Dent-29)
  • Comprehensive treatment plan from the treating and/or referring dentist/specialist indicating all completed treatment and pending treatment needs including restorative, periodontal, prosthodontic, endodontic, orthodontic and surgical services
  • Current conventional or digital radiographs (within last twelve months):
    1. Periapical radiographs of abutment teeth and bitewing radiographs:
      • must be of good diagnostic quality (i.e., size, resolution, contrast);
        and
      • must be mounted and labelled with the date of service, client name and provider name
    2. A panoramic radiograph may be submitted in addition to, but not in place of bitewing and periapical radiographs

      Note: if duplicate radiographs are submitted they must identify the right or left side of the client's mouth.

      When submitting enlarged digital radiographs, of any type, dental providers are requested to print a measurement scale on the radiograph to facilitate the assessment
  • Notation of all missing teeth
  • Periodontal charting, and/or Periodontal Screening and Recording (PSR), and/or Periodontal assessmentFootnote *
  • Periodontal measurements (6 sites/tooth) for all of the abutment teethFootnote *
  • All pertinent clinical findings/notes supporting the predetermination request

Note: At NIHB's request, diagnostic models or other documentation may be required.

8.6.2.3. Eligibility

The NIHB Program will consider coverage for a partial denture for teeth numbered 16 to 26 and 36 to 46 inclusive, under the following conditions:

  • General conditions:
    • All basic treatment must be completed including:
      • control of caries and of periodontal and periapical disease for all teeth; and
      • restoration of major structural defects in the abutment teeth
    • The space to be replaced is greater than or equal to the corresponding natural teeth (vertically and horizontally)
    • All abutment teeth must have:
      • adequate periodontal support, based on alveolar bone levels (crown to root ratio of at least 1:1) visible on submitted radiographsFootnote *; and
      • absence of active periodontal diseaseFootnote *
    • If there is an existing partial cast denture, it must be at least eight (8) years old
    • If there is an existing partial acrylic denture, it must be at least five (5) years old

      Note: If there is evidence of periodontal disease, the NIHB Program will not consider coverage for a cast partial denture. However, in such situations, the Program will consider coverage for an acrylic partial denture.Footnote *
  • Specific conditions:
    • There must be one or more missing teeth in the anterior sextant

      or
    • There must be two or more missing posterior teeth in a quadrant excluding second and third molars

8.6.3. Complete Dentures

8.6.3.1. General Principles

The general principles of complete dentures are as follows:

  • Complete dentures are covered once in any eight (8) year period per arch
  • Predetermination is not required for the replacement of standard removable complete denture provided that the existing denture is at least eight (8) years old. Dental providers should confirm client eligibility by contacting the Express Scripts Canada Provider Claims Processing Call Centre prior to providing the service.
8.6.3.2. Predetermination Documentation Requirements for Complete Dentures

The NIHB Program requires the following documentation for the review of a complete denture predetermination request:

  • Predetermination requested on one of the following forms: Complete Standard Dental Claim Form, ACDQ Dental Claim and Treatment Form, computer generated form, or NIHB Dental Claim Form (Dent-29)
  • Notation of all missing teeth or planned extractions
  • Panoramic X-ray (if available)
  • All pertinent clinical findings/notes supporting the predetermination request

Note: At NIHB's request, diagnostic models or other documentation may be required.

8.6.3.3. Eligibility

The NIHB Program will consider coverage for a complete denture:

  • for an initial placement; or
  • for replacement of an existing complete denture that is at least eight (8) years old.

8.6.4. Non-Inserted Removable Prosthodontic Policy

8.6.4.1. Standard Partial Dentures and Complete Dentures

The NIHB Program will consider paying up to 20% of the current NIHB professional fee and 100% of the laboratory fee, if applicable, for non-inserted dentures under the following conditions:

  • the denture has been completed but not inserted due to circumstances beyond the control of the dental provider;
  • the provider has made substantial efforts to contact the client to schedule an insertion appointment; and
  • the provider has communicated the details of the situation in writing to the NIHB Dental Predetermination Centre.
8.6.4.2. Immediate Dentures

The NIHB Program will consider paying up to 100% of the current NIHB professional fee and 100% of the laboratory fee, if applicable, for non-inserted immediate dentures under the following conditions:

  • the provider who manufactured the immediate denture is different from the provider who was scheduled to do the extraction(s) and insertion;
  • substantial efforts have been made by both providers to contact the client to reschedule the missed extraction/insertion appointment; and
  • the provider who manufactured the immediate denture has communicated the details of the situation in writing to the NIHB Dental Predetermination Centre.

    Note: A non-inserted denture (any type) that has been claimed and paid in full, without complying with the above noted conditions, will result in a payment recovery.
Frequency Guidelines for Dentures
Dental Procedure Frequency Guidelines
Complete/ Partial Cast Dentures (require PD) 1 per arch in any 96 months.
Partial Acrylic Dentures (require PD) 1 per arch in any 60 months
Repairs/Additions 1 per prosthesis in any 12 months.
Reline/Rebase 1 per prosthesis in any 24 months.
Tissue Conditioning 1 per prosthesis in any 24 months.

8.7 Oral Surgery Services

Implants and ridge augmentation are exclusions under the NIHB Program.

Surgical extractions as well as major surgical procedures require predetermination and must be supported by clinical findings/notes and radiographs.

Surgical extraction requests may be submitted as post-determinations and must be supported by clinical findings/notes and radiographs in order to be considered for coverage.

8.8 Orthodontic Services

           Orthodontic Policy

8.8.1. General Principles

  • The NIHB Program provides coverage for a specified range of medically necessary orthodontic services for eligible First Nations and Inuit clients, when there is a severe and functionally handicapping malocclusion as set out by the Modified Handicapping Labio-Lingual Deviation (HLD) Index.
  • The NIHB Program covers three (3) types of orthodontic treatment:
    1. Comprehensive
    2. Limited
    3. Interceptive
  • The overall cost of multiple phases of orthodontic treatment shall not exceed the total fee of one comprehensive phase, up to the maximum regional NIHB fee
  • Predetermination is required for all orthodontic services, with the exception of orthodontic examination and orthodontic diagnostic records
  • Clients are eligible for coverage for orthodontic services once in a lifetime
  • Submissions for orthodontic services will be reviewed using the two-step process detailed in Section 8.8.3

8.8.2. Eligibility Criteria

The NIHB Program will consider coverage for orthodontic treatment when eligibility and clinical criteria are met.

  • Age

    Children:

    • Under 18 years of age that meet the clinical criteria of a severe and functionally handicapping malocclusion, taking into consideration any clinical evidence associated and impacting the child’s condition

    Adults:

    • 18 years of age and over with a craniofacial anomaly (e.g., cleft lip and palate) that is associated with a severe and functionally handicapping malocclusion
  • Clinical Criteria
    • A severe and functionally handicapping malocclusion as set out by the Modified Handicapping Labio-Lingual Deviation (HLD) Index
    • Pain/discomfort or other signs and symptoms associated with a severe and functionally handicapping malocclusion, which are substantiated by objective clinical medical/dental evidence and supported with appropriate documentation beyond the clinical criteria captured in the Modified HLD Index (refer to Section 8.8.3.2)
  • Oral Health Status
    • Client must have been caries-free for a period of six (6) months prior to submitting the predetermination request; in other words, all basic dental treatment addressing any existing caries, must be completed six (6) months prior to submission; and
    • Client must have maintained a good oral hygiene for a period of six (6) months prior to submitting the predetermination request

Note: NIHB must be advised in writing by the treating provider if treatment has been discontinued due to non-compliance or poor oral health.

8.8.3. Orthodontic Submissions Review Process and Documentation Requirements

The NIHB Program must receive the complete predetermination documents prior to the client’s 18th birthdayFootnote 4 for the request to be considered for review (not applicable to craniofacial anomaly cases).

8.8.3.1. Step 1: Application of Modified HLD Index
  • Submissions will be reviewed against the Modified HLD Index
  • Predetermination must be requested on one of the following completed forms: Canadian Association of Orthodontist (CAO) Standard Orthodontic Information Form, Standard Dental Claim Form, Association des Chirurgiens Dentistes du Québec (ACDQ) Dental Claim and Treatment Plan Form, Computer generated form, or NIHB Dental Claim Form (DENT-29)
  • Pre-treatment diagnostic records must include the following:
    • diagnostic orthodontic models (in any of the formats below)
      • physical models: either trimmed stone models or 3D–printed models with the centric occlusion position marked
      • photo models where overjet, overbite and labio-lingual spread are documented in millimeters (mm)
    • cephalometric radiograph with associated scale for calibration
    • photographs: frontal and profile views; intra-oral depicting right and left occlusal relationship as well as anterior views
    • panoramic radiograph

Note: Written confirmation of client’s oral health status from the general practitioner maybe requested upon the review of the case.

8.8.3.2. Step 2: Additional consideration
  • Applicable in situations where the client’s condition requires additional consideration beyond Step 1
  • Submissions will be reviewed against all objective clinical medical/dental evidence supported with appropriate documentation for each of the following four (4) areas
    1. Principal diagnosis and significant associated diagnoses
    2. Clinical significance or functional impairment related to any clinical signs or symptoms
    3. Specific services to be rendered and anticipated time for achievement of goals
    4. Any other relevant documentation available which may assist NIHB in making a determination of the severe and functionally handicapping malocclusion

Note:

  • If all of the clinical medical/dental evidence supported with appropriate documentation listed above is provided in Step 1, it will be reviewed at Step 2
  • Additional clinical medical/dental evidence supported with documentation maybe requested upon the review of Step 2
  • Subjective statements submitted must be substantiated by objective clinical medical/dental evidence and supported with appropriate documentation

8.9 Adjunctive Services

8.9.1. Sedation and General Anaesthesia Policy

8.9.1.1. General Principles

The general principles of the sedation and general anaesthesia policy are as follows:

  • All requests related to the 90000 series codes, which include sedation, general anaesthesia and/or facility fees, require predetermination
  • The NIHB Program provides coverage for the following 90000 series codes (including facilities, where applicable):
    • Deep sedation and general anaesthesia
    • Moderate sedation:
      1. parenteral conscious sedation (intravenous and/or intramuscular);
      2. combined technique of inhalation plus intravenous and/or intramuscular injection; and
      3. nitrous oxide with oral sedation (multiple sedative drugs)
    • Minimal sedation:
      1. oral sedation;
      2. nitrous oxide; and
      3. nitrous oxide with oral sedation (single sedative drug)
  • All sedation codes include the cost of sedation medication
  • Providers must adhere to the conditions of licensing, certification, accreditation and registration as per provincial/territorial and/or dental regulations to submit a claim to the NIHB Program
  • If provinces/territories provide and cover general anaesthesia and deep sedation for dental services to residents at no charge through their provincial/territorial health care insurance plan, social programs, publicly funded programs, NIHB will not cover these benefits provided in any facility. Clients under the NIHB Program will be expected to access these dental services through their provincial/territorial health care insurance plan, social program, publicly funded program or private insurance plan.
8.9.1.2. Utilization of Private Facilities
  • The NIHB Program will not provide coverage for the use of private facilities if the client has coverage for this under their private insurance plan, provincial/territorial health care insurance plan, social program or other publicly funded program. If clients choose to use a private facility, they will be responsible for the costs incurred.
  • The NIHB Program will consider coverage for the use of a private facility on an exception basis, subject to the Program criteria and guidelines and unique regional, provincial/territorial circumstances. If NIHB is to assume any financial costs, predetermination must be obtained prior to the dental services being rendered.

8.9.2. Predetermination Documentation Requirements for Sedation and General Anaesthesia

The NIHB Program requires the following documentation for the review of a sedation/general anaesthesia predetermination request:

  • Predetermination requested on one of the following forms: Standard Dental Claim Form, ACDQ Dental Claim and Treatment Form, computer generated form, or NIHB Dental Claim Form (Dent-29)
  • Comprehensive treatment plan from the treating and/or referring dentist/specialist indicating all completed treatment and pending treatment needs including restorative, periodontal, prosthodontic, endodontic, orthodontic, and surgical services
  • Rationale and/or documents to support the request for sedation or general anaesthesia (refer to specific eligibility criteria for each method of sedation)
  • Current conventional or digital radiographs (within the last twelve months)
    1. Preoperative periapical and bitewing radiographs (if preoperative radiographs cannot be taken due to uncooperative behaviour, perioperative or postoperative radiographs must be submitted):
      • must be of good diagnostic quality (e.g., size, resolution, contrast), and
      • must be mounted and labelled with the date of service, client name and provider name
    2. A panoramic radiograph may be submitted in addition to, but not in place of bitewing and periapical radiographs

      Note: if duplicate radiographs are submitted they must identify the right or left side of the client's mouth.

      When submitting enlarged digital radiographs, of any type, dental providers are requested to print a measurement scale on the radiograph to facilitate the assessment.

  • Notation of missing teeth
  • At NIHB's request, other documentation may be required

8.9.3. General Anaesthesia and Deep Sedation

8.9.3.1. General Principles

The general principles of general anaesthesia and deep sedation are as follows:

  • A frequency limitation of once in any twelve (12) month period applies
  • The NIHB Program will cover up to a regional maximum dollar value of general anaesthesia/deep sedation and facility fees in any 12 month period
  • To limit the associated risks with repeat general anaesthesia and deep sedation, dental providers should ensure, where possible, that all dental services performed under general anaesthesia and deep sedation are completed in one session
  • If multiple appointments are required, providers must submit a predetermination request along with a comprehensive treatment plan and supporting documentation (refer to section 8.9.2.) prior to the initiation of the treatment

    Note: Stainless steel crowns and plastic crowns will be considered for:
    • clients under the age of four with high caries risk;
    • restoration of primary molars and anterior teeth with two or more carious surfaces; and/or
    • restoration of primary molars following a pulpotomy or pulpectomy.
  • Providers must ensure that other adjunctive services such as minimal or moderate sedation have been considered prior to requesting general anaesthesia or deep sedation
8.9.3.2. Coverage eligibility for clients under 12 years of age

To be eligible for coverage of general anaesthesia or deep sedation, clients under 12 years of age must have:

  • complex or extensive treatment needs; and
  • all deciduous teeth should be erupted;
    and
  • severe age related behaviour management limitations; or
  • a significant medical condition or physical impairment.

Note: If there are unerupted deciduous teeth present in the mouth please contact the NIHB Dental Predetermination Centre to discuss the predetermination request prior to proceeding with treatment.

8.9.3.3. Coverage eligibility for clients 12 years of age and older

General anaesthesia and deep sedation are not covered for the management of dental anxiety.

To be eligible for coverage of general anaesthesia or deep sedation, clients 12 years of age and older must:

  • require significant surgical procedures Footnote 1 that are medically necessary; or
  • have a significant medical condition or physical impairment.

8.9.4. Moderate Sedation

8.9.4.1. General Principles

The general principles of moderate sedation are as follows:

  • A frequency limitation of once in any twelve (12) month period applies
  • The NIHB Program will cover up to a regional maximum dollar value of moderate sedation modalities in any 12 month period
  • Applies to parenteral sedation, combined technique of inhalation plus intravenous and/or intramuscular injection, and nitrous oxide combined with oral sedative drugs
  • To limit the associated risks with repeat moderate sedation, dental providers should ensure, where possible, that all dental services performed under moderate sedation are completed in one session
  • If multiple appointments are required, providers must submit a predetermination request along with a comprehensive treatment plan and supporting documentation (refer to section 8.9.2) prior to the initiation of the treatment
  • Providers must also ensure that other adjunctive services such as minimal sedation have been considered prior to requesting moderate sedation
8.9.4.2. Coverage eligibility for clients under 12 years of age

To be eligible for coverage of moderate sedation, clients under 12 years of age must have:

  • severe age related behaviour management limitations; or
  • a significant medical condition or physical impairment;
    and
  • complex or extensive treatment needs.
8.9.4.3. Coverage eligibility for clients 12 years of age and older

Moderate sedation is not covered for the management of dental anxiety.

To be eligible for coverage of moderate sedation, clients 12 years of age and older must:

  • require significant surgical proceduresFootnote 2 that are medically necessary; or
  • have a significant medical condition or physical impairment and require complex or extensive treatment.

8.9.5. Minimal Sedation

8.9.5.1. General Principles

The general principles of minimal sedation are as follows:

  • The NIHB Program will cover up to a regional maximum dollar value of minimal sedation in any 12 month period
  • Applies to nitrous oxide, a single oral sedative drug, or a combination of nitrous oxide/oxygen and a single sedative drug
8.9.5.2. Coverage eligibility for clients under 12 years of age

To be eligible for coverage of minimal sedation, clients under 12 years of age must have:

  • severe age related behaviour management limitations;
  • a significant medical condition or physical impairment;
  • complex or extensive treatment needs; or
  • a strong gag reflex that prevents dental care.
8.9.5.3. Coverage eligibility for clients 12 years of age and older

Minimal sedation is not covered for the management of dental anxiety, however it will be considered for the management of a documented dental phobiaFootnote 3.

To be eligible for coverage of minimal sedation, clients 12 years of age and older must:

  • require significant surgical procedures that are medically necessary; or
  • have a significant medical condition or physical impairment.

9.0 Appendices

A. NIHB Regional Dental Grid

The NIHB Regional Dental Benefit Grids list what services are eligible by placing benefits into two schedules:

  • Schedule A: outlines services that may be completed and billed directly to the claims processor for payment (without requiring predetermination)
  • Schedule B: outlines services that require predetermination

NIHB Regional Dental Benefit Grids are located on the Express Scripts Canada website.

B. NIHB Dental Predetermination Centre Contact Information

Dental Services

Non-Insured Health Benefits
First Nations and Inuit Health Branch
Indigenous Services Canada
200 Eglantine Driveway
Address Locator 1902D
Ottawa, Ontario K1A 0K9

Toll-Free Telephone: 1-855-618-6291
Toll-Free Fax: 1-855-618-6290

Orthodontic Services

Non-Insured Health Benefits
First Nations and Inuit Health Branch
Indigenous Services Canada
200 Eglantine Driveway
Address Locator 1902C
Ottawa, ON K1A 0K9

Toll-Free Telephone: 1-866-227-0943
Toll-Free Fax: 1-866-227-0957

C. Client Eligibility

To be eligible for NIHB Program benefits, a person must be a Canadian resident and have the following status:

  • a registered Indian according to the Indian Act; or
  • an Inuk recognized by one of the following Inuit Land Claim organizations - Nunavut Tunngavik Incorporated, Inuvialuit Regional Corporation, Makivik Corporation. For an Inuk residing outside of their land claim settlement area, a letter of recognition from one of the Inuit land claim organizations and a birth certificate are required; or
  • a child, less than 18 months of age, whose parent is an eligible client; and
  • is currently registered or eligible for registration, under a provincial or territorial health insurance plan; and
  • is not otherwise covered under a separate agreement (e.g. a self-government agreement) with federal, provincial or territorial governments.

Note:

The following individuals are excluded from the NIHB Program:

  • First Nations and Inuit who are not residing in Canada
  • First Nations and Inuit who are incarcerated in a federal, provincial/territorial or municipal corrections facility
  • First Nations and Inuit who are in a provincially/ territorially funded institutional setting which provides its residents with supplementary health benefits as part of their care, such as nursing homes

Health benefit requests for these individuals should be submitted to the appropriate organization.

To facilitate verification, dental providers should provide the following client identification information with each claim:

  • surname (under which the client is registered);
  • given names (under which the client is registered);
  • date of birth (dd/mm/yyyy); and
  • client identification number.

It is recommended that dental providers ask clients to present their identification card upon each visit to ensure that client information is entered correctly and to protect against mistaken identity.

For recognized Inuit clients, one of the following identifiers is required:

  1. Government of the Northwest Territories health plan number, which begins with the letter "T" and is followed by seven digits. This number is valid in any region of Canada and is cross-referenced to the First Nations and Inuit Health Branch (FNIHB) Regional Office client identification number.
  2. Government of Nunavut health plan number, which is a nine-digit number starting with a "1" and ending with a "5". This number is valid in any region of Canada and is cross-referenced to the FNIH Client identification number.
  3. FNIHB Client Identification Number (N-Number), which begins with the letter "N" and is followed by eight digits. This is a client identification number issued by the First Nations and Inuit Health Branch to recognized Inuit clients.

For registered First Nations clients, one of the following identifiers is required:

  1. Indigenous and Northern Affairs Canada registration number, which is a 10-digit number. Also known as the Treaty or Status number, this registration number is the preferred method of identifying First Nations clients.
  2. FNIHB Client Identification Number (B-Number), which begins with the letter "B" and is followed by eight digits.

For infants under 18 months of age who are not yet registered with Indigenous and Northern Affairs Canada or applicable Inuit associations, dental providers can communicate with the appropriate FNIHB regional office.

More detailed information about client eligibility is included in the Dental Claims Submission Kit which can be found on the Express Scripts Canada Provider Website.

D. Appeal Process

General Information for Dental and Orthodontic Services

Clients eligible for the NIHB Program have the right to appeal the denial of a benefit with the exception of items that are identified as exclusions.

There are three levels of appeal available to NIHB clients. Appeals must be submitted in writing and must be initiated by the client/parent/guardian. At each stage, the appeal must be accompanied by supporting documentation.

At each level of the appeal process, the information will be reviewed by a different dental professional that will provide recommendations to the Program.

Following the review, the client/parent/guardian will be provided with a written explanation of the decision taken at each level of the appeal process within 30 business days from the date the Program received completed appeal documentation.

Specific information for orthodontic services

In order for a client to be eligible to appeal a decision regarding orthodontic services, a Predetermination submission must have been received by NIHB Dental Predetermination Centre (Orthodontic Services) prior to the client's 18th birthday (not applicable in dentofacial anomaly cases).

All three levels of appeal must be accompanied with the supporting documentation provided by the dental practitioner and be completed prior to the client's 19th birthday (not applicable in dentofacial anomaly cases).

The review for all three levels of appeal will be based on the most current records obtained prior to the commencement of orthodontic treatment.

If a client chooses to start an orthodontic treatment after the request for coverage was denied by the NIHB Program, the client may still access the appeal process, as long as the treatment was predetermined before the age of 18, and all levels of appeal are completed before the age of 19 (not applicable in dentofacial anomaly cases). In such situation, all three (3) levels of appeal must be initiated and submitted with all the documentation and information required for predetermination within one year period from the date of service/ insertion date (for the complete list of submission requirements, refer to Orthodontic Policy, section Predetermination Documentation Requirements for Orthodontic Services).

Mailing instructions

Please label your submission "APPEALS – CONFIDENTIAL" and address it either to the NIHB Dental Predetermination Centre (Dental Services) for dental appeals, or NIHB Dental Predetermination Centre (Orthodontic Services) for orthodontic appeals.

  • Level 1 Appeal:
    The client/parent/guardian must initiate the appeal process and address their submission to the Manager, Dental Policy Unit, Benefit Management and Review Services Division, and forward their documentation to the NIHB Dental Predetermination Centre.
  • Level 2 Appeal:
    If the client/parent/guardian does not agree with the Level 1 appeal decision, they may initiate the second level of appeal. The submission should be addressed to the Director, Benefit Management and Review Services Division, and the documentation forwarded to the NIHB Dental Predetermination Centre.
  • Level 3 Appeal:
    If the client/parent/guardian does not agree with the Level 2 appeal decision, they may initiate the third and final level of appeal. The submission should be addressed to the NIHB Director General, and the documentation forwarded to the NIHB Dental Predetermination Centre.

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E. Provider Audit Program

The NIHB Program is accountable for the expenditure of public funds and the NIHB Provider Audit Program ensures those funds are paid appropriately. The Health Information and Claims Processing Services (HICPS) contractor performs this audit function by verifying paid claims against dental records to confirm they have been billed in compliance with the terms and conditions of the NIHB Program.

If under any circumstances (e.g. through pre or post determination, audit programs) it is found that a dental provider has inappropriately billed the Program, claim payments will be recovered.

Detailed information about audit procedures and the responsibilities of dental providers for these audits are included in section 6. Provider Audit Program of the Dental Claims Submission Kit which can be found on the Express Scripts Canada Provider Website.

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