- 1.1 NIHB program dental benefits
- 1.2 Purpose of the Dental Benefit Guide
- 4.1 Coordination of benefits
- 4.2 Laboratory fee submission
- 8.1 Diagnostic services
- 8.1.1 Examinations
- 8.1.2 Radiographs
- 8.1.2.1 Frequency guidelines for radiographs
- 8.1.2.2 Focal plane tomograms and cone beam computerized tomography
- 8.2.1 Frequency guidelines for interproximal disking of teeth
- 8.2.2 Oral appliances for sleep apnea
- 8.3.1 Restorations, primary teeth
- 8.3.2 Restorations, permanent teeth
- 8.3.3 Caries, trauma and pain control
- 8.3.4 Cores and posts
- 8.3.5 Crowns
- 8.3.5.1 General principles
- 8.3.5.2 Eligibility criteria
- 8.3.5.2.1 Tooth eligibility
- 8.3.5.2.2 Tooth restorability
- 8.4.1 General principles
- 8.4.2 Eligibility criteria
- 8.4.2.1 Tooth eligibility
- 8.4.2.2 Tooth restorability
- 8.5.1 General principles
- 8.5.2 Preventive services
- 8.5.2.1 Frequency guidelines for polishing, topical fluoride treatment, topical application of an antimicrobial or remineralization agent, scaling and root planing
- 8.5.2.2 Sealants and preventive resin restorations
- 8.5.3.1 Scaling and root planing (additional units)
- 8.5.3.2 Surgical services
- 8.6.1 General principles
- 8.6.2 Removable partial dentures
- 8.6.2.1 General principles
- 8.6.2.2 Documentation requirements for predetermination and post-determination
- 8.6.2.3 Eligibility
- 8.6.3.1 General principles
- 8.6.3.2 Documentation requirements for predetermination and post-determination
- 8.6.3.3 Eligibility
- 8.6.4.1 Standard partial and complete dentures
- 8.6.4.2 Immediate partial and complete dentures
- 8.8.1 General principles
- 8.8.2 Eligibility criteria
- 8.8.3 Orthodontic submissions review process and documentation requirements
- 8.8.3.1 Step 1: Application of the Modified Handicapping Labio-Lingual Deviation (HLD) Index
- 8.8.3.2 Step 2: Additional consideration
- 8.9.1 General principles
- 8.9.2 Minimal sedation
- 8.9.2.1 General principles
- 8.9.2.2 Coverage eligibility
- 8.9.3.1 General principles
- 8.9.3.2 Coverage eligibility
- 8.9.4.1 General principles
- 8.9.4.2 Coverage eligibility
- Appendix A: NIHB Regional Dental Benefit Grids
- Appendix B: Submission of Predetermination Requests
- Appendix C: Client eligibility
- Appendix D: Appeal process
- Appendix E: Provider Claim Verification Program (PCVP)
- Appendix F: Exclusions
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 by:
- private health insurance plans
- provincial/territorial health insurance plans
- social programs
The benefits provided under the NIHB program include:
- prescription drugs and over-the-counter medications
- dental care
- vision care
- medical supplies and equipment
- mental health counselling
- 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 the following services:
- diagnostic
- preventive
- restorative
- endodontic
- periodontal
- removable prosthodontic
- oral surgery
- orthodontic
- adjunctive
The individual services are listed in the NIHB Regional Dental Benefit Grids available on the Express Scripts Canada NIHB provider and client website and are based on:
- 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
- Canadian Dental Hygienists Association (CDHA) National List of Service Codes
Terms and conditions for coverage are detailed in section 3.0 Terms and conditions
1.2 Purpose of the Dental Benefit 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 bulletins available on the Express Scripts Canada NIHB provider and client website and other communication tools.
Dental providers are advised to read and retain the most current version of the guide to ensure continued compliance with the terms and conditions of their NIHB Billing Agreement. 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 Benefit Grids, will prevail.
2.0 General principles
- 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.
- 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.
- 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.
- The NIHB program covers most dental procedures that prevent and treat dental disease or the consequences of dental disease.
- Coverage of dental services is determined on an individual basis taking into consideration criteria such as the client's oral health status.
- 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.
- Certain dental services are defined as exclusions. These services are not considered for coverage nor considered for appeal under the NIHB program. Further details are provided in Appendix F.
- 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.
- Dental benefits must be provided by an NIHB recognized dental provider who is licensed and in good standing with the regulatory body of the province/territory in which they practice. Should a provider's standing with their regulatory body change, the provider must contact Express Scripts Canada (1-888-511-4666) immediately. A dental provider includes:
- a dentist
- a dental specialist
- an independent dental hygienist
- a denturist
- policies
- guidelines and criteria
- frequency limitations
- predetermination requirements
- verify the eligibility of the client
- ensure that no limitations will be exceeded
- 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 in the Dental Claims Submission Kit available on the Express Scripts Canada NIHB provider and client website, 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. Along with supporting documentation attached to claim forms, the mandatory data elements that must be completed on forms include:
- tooth number
- procedure code
- date of service (DOS)
- client identification
- client address
- band number and/or family number
- date of birth
- provider information
- provider and client (parent/legal guardian) signatures
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 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.
- The 1 Year Policy applies to the initial claim submission and includes all subsequent resubmissions following a rejection under NIHB (for example, 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 1 year from the date of service.
Claims older than 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:
- receipts for proof of payment
- NIHB Client Reimbursement 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
If applicable, a detailed statement or Explanation of Benefits (EOB) from all other health plans and programs must be provided.
Note: Credit card/debit (Interac) slips, cash register receipts or statements of account are not accepted.
Quick links
- NIHB Client Reimbursement Form: available at the NIHB Client Reimbursement webpage on the Express Scripts Canada NIHB provider and client website
- NIHB Dental Claim, Predetermination & Post-Determination Form (Dent-29): available at the NIHB dental forms webpage on the Express Scripts Canada's NIHB provider and client website
4.1 Coordination of benefits
Clients are required to access private (employer-sponsored) health benefit plans for which they are eligible prior to accessing dental benefits under the NIHB program. The other payer will provide an Explanation of Benefit (EOB) form that must be sent to the NIHB program. The NIHB program will then coordinate payment with the other payer on eligible benefits. When an NIHB-eligible client is also covered by the Canadian Dental Care Plan (CDCP), claims should be submitted to NIHB first.
Where a client is no longer eligible for coverage from another payer, the provider or client can contact the NIHB Call Centre at Express Scripts Canada to update the client's profile.
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 statement
Indigenous Services Canada's NIHB program has the responsibility to protect personal information under its control in accordance with the Privacy Act and its related Treasury Board policy and directives, and is responsible for ensuring that the personal information collected is limited to that which is necessary to administer the program.
For more information, please contact Indigenous Services Canada's Access to Information and Privacy (ATIP) Coordinator at 819-997-8277 or aadnc.atiprequest-aiprpdemande.aandc@canada.ca. You also have the right to file a complaint with the Privacy Commissioner of Canada if you think your personal information has been handled improperly.
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, for example, temporomandibular joint therapy and appliances, fixed prosthodontics (bridges and all bridge related procedures), implants and all implant related procedures, veneers, cosmetic services and appliances to treat bruxism. Further details are provided in Appendix F.
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 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 1 year (in other words, within the last 12 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 one of the following forms:
- Standard Dental Claim Form
- Association des chirurgiens dentistes du Québec (ACDQ) Dental Claim and Treatment Plan Form
- computer generated form
- Canadian Dental Hygienists Association (CDHA) National Dental Hygiene Claim Form
- NIHB Dental Claim Form (Dent-29)
- periapical and bitewing radiographs:
- must be of good diagnostic quality (in other words, size, resolution, contrast); and
- must be mounted and labelled with the date of service, client name and provider name
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 17 years of age are eligible for up to 4 examinations and those 17 and older are eligible for up to 3 examinations in any 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
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, independent dental hygienists 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 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 1 year of the predetermination submission.
8.1.2.1 Frequency guidelines for radiographs
Frequency guidelines for radiographs
Dental procedure Frequency guidelines Intraoral periapical radiographs (11-15 films), complete series 1 in any 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 of 60 months, and vice versa.
8.1.2.2 Focal plane tomograms and cone beam computerized tomography
Focal plane tomograms and cone beam computerized tomography (CBCT) services are eligible for coverage under the NIHB program.
These services require predetermination and must be supported by chart notes or reports.
The NIHB program will consider coverage for focal plane tomograms and CBCT services under the following circumstances:
- localization of unerupted or impacted teeth and proximal to important anatomical structures
- assessment of endodontically treated teeth for re-treatment and apicoectomy/retrofilling
- dentoalveolar trauma
- assessment of selected cases of infrabony periodontal defects, when conventional radiography is inconclusive to lead a treatment decision
- orthognathic surgery
Note: The NIHB program will not consider coverage for focal plane tomograms and CBCT services for caries detection or orthodontic evaluations.
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, topical fluoride treatments, pit and fissure sealants/preventive restorative resin services, please refer to the Preventive and Periodontal Policy in section 8.5 Periodontal services.
8.2.1 Frequency guidelines for interproximal disking of teeth
Frequency guidelines for interproximal disking of teeth
Dental procedure Frequency guidelines Interproximal disking of teeth (requires predetermination) 1 unit in any 12 months 8.2.2 Oral appliances for sleep apnea
Oral appliances for sleep apnea are not eligible services under the NIHB program. However, they will be considered for coverage on an exception basis for mild and moderate sleep apnea cases, under the following conditions:
- the request has been submitted for predetermination
- the client is 18 years of age or older
- NIHB records indicate that:
- the client met the NIHB criteria for a Continuous Positive Airway Pressure (CPAP) rental trial
- CPAP therapy was trialed for a minimum period of 3 months; and
- the client was unable to adhere to CPAP therapy during the trial period as deemed by the NIHB Medical Supplies and Equipment (MSE) benefit unit review process
Note: Oral appliances to treat snoring will not be considered for coverage.
For information regarding CPAP therapy or other NIHB Medical Supplies and Equipment benefits, clients are encouraged to contact their physician or nurse practitioner.
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 2 year time frame are subject to audit and require a written rationale documented in the client's chart on the date of service delivery.
Restorations for incisal wear involving 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 incisor teeth 51, 52, 61, 62, 71, 72, 81, 82:
- clients must be under the age of 5
- tooth is eligible once 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 1 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 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 1 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 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 1 visit the cost applicable to the collective number of distinct surfaces restored, up to a maximum cost of 5 surface restorations or 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 5 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
If requested for the same date of service and for the same tooth, 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
- root canal
8.3.4 Cores and posts
Cores are eligible only if the existing restoration is greater than 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. Tooth is eligible once in any 12-month period by the same provider, or different provider in the same office.
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 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 (standalone procedure) and prefabricated posts in combination with cores (require predetermination) 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 following types of single unit crowns are eligible for coverage:
- cast full metal
- porcelain/ceramic-fused to metal
- porcelain/ceramic
- 4 crowns in any 10 year period per client
- 1 crown per eligible tooth in any 8 year period (96 months)
- 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 Eligibility criteria
8.3.5.2.1 Tooth eligibility
The NIHB program will consider coverage of a single unit crown on:
- incisors, canines, bicuspids, first and second molars; and
- third molars where the first and the second molars are missing and the third molar is in occlusion with a prosthetic or natural molar
8.3.5.2.2 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 3 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 5 continuous surfaces
8.3.5.3 Documentation requirements for predetermination and post-determination
- Predetermination and post-determination must be requested on one of the following completed forms:
- Standard Dental Claim Form
- Association des chirurgiens dentistes du Québec (ACDQ) Dental Claim and Treatment Plan Form
- computer generated form
- NIHB Dental Claim Form (DENT-29)
- periapical and bitewing radiographs
- postoperative periapical radiograph must be submitted for a tooth that has been endodontically treated in the last 12 months
- panoramic radiograph when it is not possible to obtain periapical or bitewing radiographs
Note: For detailed specifications, please refer to section 7.0 Submission requirements.
8.3.5.4 Non-Inserted Crown Policy
For non-inserted crowns, the NIHB program will consider paying up to 20% of the current NIHB professional fee and up to 100% of a reasonable laboratory fee associated with the fabrication of a crown, if applicable, 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
- 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 without complying with the above noted conditions and has been paid in full by the NIHB program will result in a payment recovery.
Frequency guidelines for crowns
Dental procedure Frequency guidelines Crowns (require predetermination) 4 in any 10 years per client 8.4 Endodontic services
Endodontic Policy
8.4.1 General principles
- Predetermination is not required for standard root canal treatment (RCT) on anterior teeth, bicuspids, and first and second molars
- Predetermination is required for root canal re-treatment, apicoectomy, retrofilling on all teeth, and standard root canal treatment on third molars
- There is a frequency limitation of 1 root canal re-treatment, 1 apicoectomy and 1 retrofilling per tooth, per lifetime
- The NIHB program will consider coverage for a root canal treatment when the tooth eligibility and restorability criteria have been met
- The NIHB program will not consider coverage for a root canal treatment 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, any paid standard root canal treatment observed in the supporting documentation provided that were claimed without a predetermination and determined non-compliant with the Endodontic Policy, will be subject to payment recovery
- For recurrent non-compliant providers, the NIHB program may reinstate the predetermination requirement for a standard root canal treatment
8.4.2 Eligibility criteria
8.4.2.1 Tooth eligibility
The NIHB program will consider coverage of a root canal treatment on:
- incisors, canines, bicuspids, first and second molars; and
- third molars where the first and the second molars are missing and the third molar is in occlusion with a prosthetic or natural molar
8.4.2.2 Tooth restorability
The NIHB program will consider coverage of a root canal treatment 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
- a tooth that does not require any additional dental treatment such as crown lengthening, root resectioning or orthodontic treatment
8.4.3 Pulpectomies and pulpotomies
- Coverage for pulpectomy/pulpotomy is 1 per tooth/per lifetime
- Pulpotomies and pulpectomies are eligible on primary incisors (teeth number 51, 52, 61, 62, 71, 72, 81 and 82) only for clients under the age of 5
- Incomplete approved root canal treatment requests will be paid to the equivalent of a pulpectomy
- The final fee for a root canal treatment includes the cost associated with a pulpectomy/pulpotomy and open and drain within the 3 month period prior to the completion of the root canal treatment, when performed by the same provider or different provider in the same office
- The final fee for a root canal treatment or pulpectomy/pulpotomy includes the fee for the temporary restoration and its replacement if required
- Stainless steel crowns are indicated for restoring teeth following either a pulpectomy or pulpotomy
8.4.4 Documentation requirements for predetermination and post-determination
- Predetermination and post-determination must be requested on one of the following completed forms:
- Standard Dental Claim Form
- Association des chirurgiens dentistes du Québec (ACDQ) Dental Claim and Treatment Plan Form
- computer generated form
- NIHB Dental Claim Form (DENT-29)
- periapical and bitewing radiographs
- a panoramic radiograph when is not possible to obtain periapical or bitewing radiographs
Note: For detailed specifications, please refer to section 7.0 Submission requirements.
Frequency guidelines for root canal therapy
Dental procedure Frequency guidelines Root canal re-treatment, apicoectomy, retrofilling 1 root canal re-treatment, 1 apicoectomy and 1 retrofilling per tooth, per lifetime 8.5 Periodontal services
Preventive and Periodontal Policy
8.5.1 General principles
The general principles on the preventive and periodontal 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 Frequency guidelines for polishing, topical fluoride treatment, topical application of an antimicrobial or remineralization agent, scaling and root planing)
- 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, topical fluoride treatment, topical application of an antimicrobial or remineralization agent, scaling and root planing
Footnote for table 88.5.2.2 Sealants and preventive resin restorations
- Clients 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 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 Frequency guidelines for polishing, topical fluoride treatment, topical application of an antimicrobial or remineralization agent, scaling and root planing)
- 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
- 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 (predetermination required):
- gingivoplasties/gingivectomies for the treatment of drug-induced gingival hyperplasia that is unresponsive to non-surgical periodontal therapy
- 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
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
- Association des chirurgiens dentistes du Québec (ACDQ) Dental Claim and Treatment Plan Form
- computer generated form
- Canadian Dental Hygienists Association (CDHA) National Dental Hygiene Claim Form
- NIHB Dental Claim Form (Dent-29)
- periapical and bitewing radiographs:
- must be of good diagnostic quality (in other words, size, resolution, contrast), and
- must be mounted and labeled with the date of service, client name, and provider name
- 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
- abscess/fistula
Frequency guidelines for the management of oral disease
Dental procedure Frequency guidelines Management of oral disease 2 units in any 12 month period 8.6 Prosthodontic services – removable prosthodontics
Removable Prosthodontic Policy
8.6.1 General principles
The general principles of the Removable Prosthodontic Policy are as follows:
- 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 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 3 months prior to the request
- There are frequency guidelines applicable to partial and complete dentures. Within their respective frequency period, replacement with any type of dentures will not be considered for coverage; however, dentures will be considered for modifications as per the needs of the client. If for specific reasons modifications are not possible, the NIHB program may consider denture replacement within their frequency periods as long as the client's condition meets the established guidelines and criteria of the Removable Prosthodontic Policy. Predetermination is required and must be supported with detailed information and rationale.
8.6.2 Removable partial dentures
8.6.2.1 General principles
The general principles of removable partial dentures are as follows:
- Predetermination is required for the initial placement of removable partial dentures
- Predetermination is not required for the replacement of a removable partial denture, provided that the existing partial denture meets its frequency eligibility:
- Removable partial acrylic dentures are covered once in any 5 year period (60 months) per arch
- Removable partial cast dentures are covered once in any 8 year period (96 months) per arch
8.6.2.2 Documentation requirements for predetermination and post-determination for partial dentures
- Predetermination and post-determination must be requested on one of the following completed forms:
- Standard Dental Claim Form
- Association des chirurgiens dentistes du Québec (ACDQ) Dental Claim and Treatment Plan Form
- computer generated form
- NIHB Dental Claim Form (Dent-29)
- periapical radiographs of abutment teeth and bitewing radiographs
- panoramic radiograph when it is not possible to obtain periapical or bitewing radiographs
- photos of stone models (3) (upper and lower separate, and in occlusion)
- photos of the upper and lower maxillary (3) (upper and lower separate, and in occlusion)
- stone models (upper and lower)
Note: For detailed specifications, please refer to section 7.0 Submission requirements.
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
- There must be 1 or more missing teeth in the anterior sextant
or - There must be 2 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:
- Predetermination is not required for standard complete dentures. All other types of complete dentures (for example, overdentures, immediate) require predetermination
- Complete dentures are covered once in any 8 year period per arch
8.6.3.2 Documentation requirements for predetermination and post-determination for complete dentures
- Predetermination and post-determination must be requested on one of the following completed forms:
- Standard Dental Claim Form
- Association des chirurgiens dentistes du Québec (ACDQ) Dental Claim and Treatment Plan Form
- computer generated form
- NIHB Dental Claim Form (Dent-29)
Note: For detailed specifications, please refer to section 7.0 Submission requirements.
8.6.3.3 Eligibility
The NIHB program will consider coverage for a complete denture:
- for an initial placement
- for replacement of an existing complete denture that is at least 8 years old
8.6.4 Non-inserted Removable Prosthodontic Policy
8.6.4.1 Standard partial and complete dentures
For non-inserted standard partial and complete dentures, the NIHB program will consider paying up to 50% of the current NIHB professional fee and up to 100% of a reasonable laboratory fee associated with the fabrication of a denture, if applicable, under the following conditions:
- the partial or complete denture has been fabricated 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 partial and complete dentures
For non-inserted immediate partial and complete dentures, the NIHB program will consider paying up to 50% of the current NIHB professional fee and up to 100% of a reasonable laboratory fee associated with the fabrication of a denture, if applicable, under the following conditions:
- the provider who manufactured the immediate denture is different from the provider who was scheduled to do the extractions 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.
- A non-inserted denture of any type that has been claimed without complying with the above noted conditions and has been paid in full by the NIHB program will result in a payment recovery.
- At the NIHB program's discretion, providers may be required to provide a detailed invoice for any laboratory work.
Frequency guidelines for dentures
Dental procedure Frequency guidelines Complete dentures 1 per arch in any 96 months. Partial cast dentures (initial placement require predetermination) 1 per arch in any 96 months Partial acrylic dentures (initial placement require predetermination) 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
Predetermination is not required for the majority of extraction procedure codes, including uncomplicated and surgical extractions.
Major surgical procedures (that is, tooth exposure, fracture reduction, etc.) require predetermination and must be supported by clinical findings, notes and radiographs.
Implants and all implant related procedures are exclusions under the NIHB program.
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 documents Modified HLD Index and Modified HLD Index - Guidelines are available at the NIHB dental forms webpage on the Express Scripts Canada NIHB provider and client website.
- The NIHB program covers 3 types of orthodontic treatment:
- Comprehensive
- Limited
- Interceptive
- The overall cost of multiple phases of orthodontic treatment shall not exceed the total fee of 1 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 2-step process detailed in Section 8.8.3 Orthodontic submissions review process and documentation requirements
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 with the child's condition that impacts the child
- 18 years of age and over with a craniofacial anomaly (for example, cleft lip and palate) that is associated with a severe and functionally handicapping malocclusion
- A severe and functionally handicapping malocclusion as set out by the Modified Handicapping Labio-Lingual Deviation (HLD) Index
- Pain/discomfort associated with a severe and functionally handicapping malocclusion
- Client must be caries-free and demonstrate good oral hygiene at the time of submitting the predetermination request. In other words, all basic dental treatment addressing any existing decay (cavities) must be completed prior to submission
Note: Client must maintain good oral hygiene over the course of the orthodontic treatment. 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 birthday Footnote 1 for the request to be considered for review (not applicable to craniofacial anomaly cases).
8.8.3.1 Step 1: Application of the Modified Handicapping Labio-Lingual Deviation (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
- NIHB Dental Claim Form (DENT-29)
- 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)
Note: Written confirmation of client's oral health status from the general practitioner may be 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 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
- 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
Sedation and General Anesthesia Policy
8.9.1 General principles
- The NIHB program provides coverage for the following sedation services:
- Minimal sedation
- Moderate sedation
- Deep sedation and general anesthesia (including facilities where applicable)
- restoration of primary and permanent teeth with extensive caries, cervical decalcification, and/or developmental defects (for example, hypoplasia, hypocalcification)
- following pulpotomy or pulpectomy
- when failure of other available restorative materials is likely (for example, interproximal caries extending beyond line angles, patients with bruxism)
- definitive restorative treatment for high caries-risk children
- intermediate restoration of fractured teeth
8.9.2 Minimal sedation
8.9.2.1 General principles
- Applies to nitrous oxide, a single oral sedative drug, or a combination of nitrous oxide and a single oral sedative drug
- Predetermination is not required for minimal sedation eligible procedure codes
- There is a frequency limitation of 4 sessions in any 12 month period
- Additional sessions above frequency will be considered through predetermination with written justification
8.9.2.2 Coverage eligibility
Clients aged 0 to 11 years
- Treatment cannot be rendered in a normal clinical setting without sedation
Clients aged 12 years and older
- Treatment attempted and was unsuccessful in a normal clinical setting without sedation; or
- Significant mental and/or physical impairment
8.9.3 Moderate sedation
8.9.3.1 General principles
- Predetermination is required for moderate sedation (in emergency situations, post-determination will be considered)
- Providers are to ensure that other modes of sedation (for example, minimal sedation) have been attempted in a normal clinical setting, when possible, prior to requesting moderate sedation
- There is a frequency limitation of 1 session in any 12 month period
- Additional sessions above frequency will be considered with written justification
- To limit the associated risks with repeat moderate sedation sessions, when possible, providers are strongly encouraged to complete all necessary treatment in 1 session
8.9.3.2 Coverage eligibility
Clients aged 0 to 11 years
- Complex or extensive treatment needs; or
- Age-related behaviour management issues, significant mental and/or physical impairment
Clients aged 12 years and older
- Complex or extensive treatment needs; or
- Significant mental and/or physical impairment
8.9.4 Deep sedation and general anesthesia
8.9.4.1 General principles
- Predetermination is required for deep sedation and general anesthesia (in emergency situations, post-determination will be considered)
- Providers are to ensure that other modes of sedation (for example, minimal and moderate sedation), when possible, have been attempted in a normal clinical setting prior to requesting deep sedation or general anesthesia
- There is a frequency limitation of 1 session in any 12 month period
- To limit the associated risks with repeat deep sedation or general anesthesia sessions, when possible, providers are strongly encouraged to complete all necessary treatment in 1 session
- Pediatric clients who require more than 1 deep sedation/general anesthesia session should be considered for referral to a specialist, when possible
8.9.4.2 Coverage eligibility
Clients aged 0 to 11 years
- Complex or extensive treatment needs, when all deciduous molars are erupted; or
- Age-related behaviour management issues, significant mental and/or physical impairment
Clients aged 12 years and older
- Complex or extensive treatment needs; or
- Significant mental and/or physical impairment
8.9.5 Documentation requirements for predetermination and post-determination
- Predetermination and post-determination must be requested on one of the following completed forms:
- Standard Dental Claim Form
- Association des chirurgiens dentistes du Québec (ACDQ) Dental Claim and Treatment Plan Form
- computer generated form
- NIHB Dental Claim Form (DENT-29)
- Preoperative periapical and bitewing radiographs (if preoperative radiographs cannot be taken due to uncooperative behaviour, perioperative or postoperative radiographs may be submitted);
or - A panoramic radiograph when it is not possible to obtain periapical or bitewings
Note: For detailed specifications, please refer to section 7.0 Submission requirements in the NIHB Dental Benefits Guide.
9.0 Appendices
Appendix A: NIHB Regional Dental Benefit Grids
The NIHB Regional Dental Benefit Grids list what services are eligible by placing benefits into 2 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 NIHB provider and client website.
Appendix B: Submission of Predetermination Requests
Predetermination requests can be submitted by mail or online:
- Online submission: providers will need to create a secure web-based account on the Express Scripts Canada NIHB provider and client website.
- Mail submissions must be addressed either to:
- NIHB Dental Predetermination Centre (Dental Services) for dental predetermination requests; or
- NIHB Dental Predetermination Centre (Orthodontic Services) for orthodontic predetermination requests
Predetermination requests submitted by email will not be accepted to ensure client confidentiality.
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 0K9Toll-Free Telephone: 1-855-618-6291
Toll-Free Fax: 1-855-618-6290Orthodontic services
Non-Insured Health Benefits
First Nations and Inuit Health Branch
Indigenous Services Canada
200 Eglantine Driveway
Address Locator 1902C
Ottawa, ON K1A 0K9Toll-Free Telephone: 1-866-227-0943
Toll-Free Fax: 1-866-227-0957Appendix C: Client eligibility
The provider must verify that the individual is eligible for benefits under Indigenous Services Canada's NIHB program and identify any other benefit coverage available to the client, if applicable.
To be eligible, a client must be a resident of Canada, and one of the following:
- a registered First Nations individual who is registered according to the Indian Act (commonly referred to as a "Status Indian")
- an Inuk recognized by one of the Inuit land claim organizations as outlined in Inuit client eligibility for NHIB
- a child less than 2 years old, whose parent is an NIHB-eligible client
Refer to the Who is eligible for the NIHB program webpage or contact the NIHB regional office for information.
More detailed information about Client Identification and Eligibility is also provided in section 4 of the Dental Claims Submission Kit available on the Express Scripts Canada NIHB provider and client website.
Appendix 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 3 levels of appeal available to NIHB clients. At each level, the appeal must be initiated by the client, the parent/legal guardian or a client representative, and authorization must be submitted in writing (dated and signed letter, including the date of birth and identification (ID) number). At each level, the appeal must also be accompanied by supporting documentation, including new information from the dental or orthodontic service provider and an appeal letter.
Each level of appeal is reviewed by a different dental professional.
Following the review of each level of appeal, the client, parent/legal guardian or client representative will be provided with a written explanation of the decision within thirty (30) business days after receiving completed appeal documentation, 80% of the time, under normal circumstances. For more details, please consult the section of the NIHB website entitled After you submit your appeal.
Specific information for dental services
For the complete list of submission requirements, please refer to section 7.0 Submission requirements
Specific information for orthodontic services
In order for a client to be eligible to appeal a decision for 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 craniofacial anomaly cases).
All 3 levels of appeal must be accompanied with the supporting documentation provided by the dental or orthodontic service provider and be completed prior to the client's 19th birthday (not applicable in craniofacial anomaly cases).
The review at all 3 levels of appeal is based on the most current orthodontic records obtained prior to the commencement of orthodontic treatment.
If a client chooses to start 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 3 levels of appeal are completed before the age of 19 (not applicable in craniofacial anomaly cases). In such situations, all 3 levels of appeal must be initiated and submitted with all the supporting documentation and complete information required for predetermination within the 1 year period from date of service or the date of insertion of orthodontic appliance/braces. For the complete list of submission requirements, please refer to section 8.8.3 Orthodontic submissions review process and documentation requirements.
Where to send appeals for dental benefits (including orthodontics)
Clients can submit appeal requests by mail or online:
- Online submission: clients will need to create a secure web-based account on the Express Scripts Canada NIHB provider and client website.
- Mail submissions: the envelope must be labelled "APPEAL—CONFIDENTIAL" and be addressed either to:
- NIHB Dental Predetermination Centre (Dental Services) for dental appeals, or
- NIHB Dental Predetermination Centre (Orthodontic Services) for orthodontic appeals
Appeal requests submitted by email will not be accepted to ensure client confidentiality.
The letter of appeal and supporting documents are to be addressed to a different program official at each appeal level.
Level 1 appeal
To begin the appeal process, the client must address all documents to the Director, Dental Policy Development Division.
Level 2 appeal
The client may choose to have the appeal reviewed at the level 2 stage if:
- the client does 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 the dental or orthodontic service provider
The client must address all documents to the Director, Benefit Management and Review Services Division.
Level 3 appeal
The client may choose to have the appeal reviewed at the final level 3 stage if:
- the client does 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 the dental or orthodontic service provider
The client must address all documents to the Director General, NIHB program.
Quick links
- Appealing a decision under the NIHB program
- Contact the NIHB program – Dental benefits
Appendix E: Provider Claim Verification Program (PCVP)
As part of the NIHB program's risk management activities, Indigenous Services Canada has mandated its claims processor to maintain a set of pre-payment and post-payment processes, including claim verification activities.
This function incorporates the review of claims against records to confirm compliance with the terms and conditions of the NIHB program. If under any circumstances it is found that a provider has inappropriately billed the program, claim payments will be recovered, either by direct payment from the provider or withheld from future provider claim statements.
Detailed information about the Provider Claim Verification Program and procedures is included in section 6 of the Dental Claims Submission Kit available on the Express Scripts Canada NIHB provider and client website.
Appendix F: 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. These services include, without being limited to:
- veneers in composite or ceramic
- all 3/4 crowns
- cosmetic treatment, including teeth whitening
- inlays/onlays in composite, precious metal or ceramic
- temporomandibular joint therapy and appliances
- fixed prosthodontics (bridges and all bridge related procedures)
- periodontal appliances, including bruxism appliances (night guards)
- mouth guards
- crown lengthening
- implants and all implant related procedures
- bone grafts
- extensive rehabilitation
- fluorescent diagnostic light
- oral myofunctional therapies and appliances
Footnotes
Footnote 1As per the July 2018 Orthodontic Policy update, clients who did not receive approval for orthodontic coverage between March 24, 2016 and July 31, 2018 can resubmit their original request for consideration under the updated criteria and process outlined in this section. Clients must submit a signed letter, requesting a reconsideration of the case, as well as pre-treatment orthodontic diagnostic records obtained through their orthodontist. As per the updated criteria outlined in section 8.8.2 Eligibility criteria, pain or discomfort associated with a severe and functionally handicapping malocclusion will be considered for coverage.
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- All basic treatment must be completed including: