Dental Benefits Guide for First Nations and Inuit: Non-Insured Health Benefits program

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.

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.

8.1.3 Laboratory tests, analysis

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

8.2.1 Frequency guidelines for interproximal disking of teeth

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
• the request is supported with a current prescription within 12 months from a physician or nurse practitioner
• the oral sleep apnea appliance is requested within 24 months of the CPAP trial

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.

8.3.1 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.

8.3.5 Crowns

Crown 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

8.4.3 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)
• Proposed treatment plan
• Radiographs (within last 12 months):
  • periapical and bitewing radiographs
  • a panoramic radiograph when is not possible to obtain periapical or bitewing radiographs
• 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

Note: For detailed specifications, please refer to section 7.0 Submission requirements.

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

8.5.3 Periodontal services

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)
• comprehensive treatment plan from the treating and/or referring dental provider, 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 12 months):
  • 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
  • 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
  • abscess/fistula
• periodontal diagnosis and prognosis
• all pertinent clinical findings/notes supporting the predetermination request

Removable Prosthodontic 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:
  1. Comprehensive
  2. Limited
  3. 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

  Adults:

  • 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
• Clinical criteria
  • 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
• Oral health status
  • 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).

Sedation and General Anesthesia Policy

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

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.