Appealing a decision under the NIHB Program – 4. Submit an appeal for dental benefits (including orthodontics)

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4. Submit an appeal for dental benefits including orthodontics

When you appeal a dental service, the documents you provide must include:

  • one of the following completed forms:
    • Canadian Dental Association (CDA) Standard Dental Claim Form
    • Non-Insured Health Benefits (NIHB) Dental Claim Form (DENT-29)
    • Computer generated claim form (specific to your provider office)
    • Association des chirurgiens dentistes du Québec (ACDQ) Dental Claim and Treatment Plan Form
  • a comprehensive treatment plan from the treating and/or referring dentist or specialist
    • the plan must indicate all completed treatment and pending treatment needs, including services that are:
      • surgical
      • restorative
      • endodontic
      • periodontal
      • orthodontic
      • prosthodontic
  • current (within the last 12 months) conventional or digital radiographs (X-rays), including:
    • periapical and bitewing
    • panoramic (if available)
  • a record of all missing teeth
  • any or all of the following information:
    • periodontal charting
    • periodontal assessment
    • periodontal screening and recording (PSR)
    • periodontal tooth specific measurements (6 sites per tooth), where applicable
  • all pertinent clinical findings and notes supporting the request
  • a dated appeal letter signed by the client, parent or legal guardian, or client's representative, which includes the client's:
    • name
    • date of birth
    • identification (ID) number

When you appeal an orthodontic service, the documents you provide must include:

  • one of the following completed forms:
    • Canadian Association of Orthodontists (CAO) Standard Orthodontic Information Form
    • CDA Standard Dental Claim Form
    • ACDQ Dental Claim and Treatment Plan Form
    • Computer generated claim form (specific to your provider office)
    • NIHB Dental Claim Form (DENT-29)
  • pre-treatment diagnostic records including 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 may be requested upon the review of the case.

  • all objective clinical medical/dental evidence supported with appropriate documentation for each of the following four (4) areas:
    • principal diagnosis and significant associated diagnoses
    • clinical significance or functional impairment related to any clinical signs or symptoms
    • specific services to be rendered and anticipated time for achievement of goals
    • any other relevant documentation available which may assist NIHB in making a determination of the severe and functionally handicapping malocclusion

Note: Subjective statements submitted must be substantiated by objective clinical medical/dental evidence and supported with appropriate documentation.

  • a dated appeal letter signed by the client, parent or legal guardian, or client's representative, is required which includes the client's:
    • name
    • date of birth
    • identification (ID) number

Where to send your dental benefits (including orthodontics) appeal

You must mail all documents to the NIHB Dental Predetermination Centre. Email requests will not be accepted, to ensure client confidentiality.Please label your envelope "APPEAL-CONFIDENTIAL" and address it either to:

  • NIHB Dental Predetermination Centre (Dental Services) for dental appeals, or
  • NIHB Dental Predetermination Centre (Orthodontic Services) for orthodontic appeals

Your letter of appeal and supporting documents are to be addressed to a different Program official at each appeal level. The information will be reviewed at each level by a different health professional that will provide recommendations to the Program. Services that are identified as exclusions under the NIHB Program will not be considered for appeal.

Level 1 appeal

To begin the appeal process, you must address all documents to the Director, Dental Policy Development Division.

Level 2 appeal

You may choose to have the appeal reviewed at the level 2 stage if:

  • you do not agree with the level 1 appeal decision
  • there is new information available for review since the last appeal

The submission should include:

  • the initial documentation submitted
  • any additional or new supporting information from your dental or orthodontic service provider

You must address all documents to the Director, Benefit Management and Review Services Division.

Level 3 appeal

You may choose to have the appeal reviewed at the final level 3 stage if:

  • you do not agree with the level 2 appeal decision
  • there is new information available for review since the last appeal

The submission should include:

  • the initial documentation submitted
  • any additional or new supporting information from your dental or orthodontic service provider

You must address all documents to the Director General, NIHB Program.

Orthodontic appeals

To be eligible for an appeal of orthodontic benefits, a predetermination submission must have been made before the client turned 18 years old. There is no age limit for predetermination submission for craniofacial anomaly cases. The review for all appeal levels will be based on current records obtained before the start of orthodontic treatment. If you start an orthodontic treatment following a denial for service coverage, you may still access the appeal process. You can appeal as long as:

  • the treatment was predetermined before the age of 18
  • all 3 levels of appeal are completed before the age of 19

There is no age limit to appeal for craniofacial anomaly cases. You must have submitted all required documents for each appeal level within a year from the date of service or date of insertion of orthodontic appliance/braces.

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