Procedures for Appeals

When coverage for a benefit through the Non-Insured Health Benefits (NIHB) Program has been denied, the recipient or parent/guardian of the recipient has the right to appeal the decision.

There are three levels of appeal available which only the recipient or parent/guardian can initiate. In order for a case to be reviewed as an appeal, a letter from the recipient or parent/guardian, accompanied by supporting information from the provider or prescriber must be submitted to the Non-Insured Health Benefits Program. This information includes:

1. The condition for which the benefit is being requested.
2. The diagnosis and prognosis, including what other alternatives have been tried.
3. Relevant diagnostic test results.
4. Justification for the proposed treatment and any additional supporting information.

The recipient or parent/guardian should submit their letter of appeal and supporting documentation by mail, clearly marked "APPEALS-CONFIDENTIAL".

Upon receiving the submission, the NIHB Program will arrange to have the case reviewed by an appeals committee of medical, dental, orthodontic or vision professionals. The decision will be made based on the specific needs of the recipient, accumulated research, the availability of alternatives and NIHB policy. The recipient or parent/guardian will be provided with a written explanation of the decision taken. If the recipient or parent/guardian has not heard within one month of submitting the appeal, they may contact the Regional Office for an update. For appeals for orthodontic benefits, they may contact the Orthodontic Review Centre for an update.

Where to Submit an Appeal for Drug Benefits

To initiate an appeal, the recipient should submit their documentation, addressed to the Director, NIHB Drug Exception Centre, and mailed to the Drug Exception Centre.

If the recipient does not agree with the Level 1 Appeal decision, the recipient may choose to have the appeal reviewed at the second level. The submission should be addressed to the Director, Benefit Management, and mailed to the Non-Insured Health Benefits Program.

If the recipient does not agree with the Level 2 Appeal decision, the recipient may choose to have the appeal reviewed at the third and final level. The submission should be addressed to the NIHB Director General, and mailed to the Non-Insured Health Benefits Program.

Where to Submit an Appeal for Dental, Medical Supplies and Equipment, Vision, Mental Health and Medical Transportation Benefits

To initiate an appeal, the recipient should submit their documentation addressed to the NIHB Regional Manager, clearly marked "APPEALS-CONFIDENTIAL" and mail it to the Regional Office.

If the recipient does not agree with the Level 1 Appeal decision, the recipient may choose to have the appeal reviewed at the second level. The submission should be addressed to the NIHB Regional Director, and mailed to the Regional Office.

If the recipient does not agree with the Level 2 Appeal decision, the recipient may choose to have the appeal reviewed at the third and final level. The submission should be addressed to the NIHB Director General, and mailed to the Non-Insured Health Benefits Program.

Where to Submit an Appeal for Orthodontic Benefits

The appeal must be submitted before the child reaches the age of 18. No appeals will be considered after the recipient's 18th birthday.

For an appeal for orthodontic benefits, the following information and diagnostic test results must be provided:

• Diagnostic Orthodontic Models -- soaped and trimmed (mounted or unmounted)
• Cephalometric -- radiograph(s) and tracing
• Photographs -- 3 intra oral and 3 extra oral
• Panoramic radiograph or Full mouth survey
• Treatment plan, estimated duration of active and retention phases of treatment and costs submitted either on a NIHB Orthodontic Summary Sheet, CAO Standard Orthodontic Information Form or letter on the Orthodontist's letterhead
• Completed NIHB Dent-29 Form
• Parent/Guardian signature (including Band name and number and/or date of birth)

To initiate an appeal, the parent/guardian should submit their documentation addressed to the NIHB Orthodontic Consultant, and faxed to the Orthodontic Review Centre.

If the parent/guardian does not agree with the Level 1 Appeal decision, the parent/guardian may choose to have the appeal reviewed at the second level. The submission should be addressed to the Director, Benefit Management, and faxed to the Orthodontic Review Centre.

If the parent/guardian does not agree with the Level 2 Appeal decision, the parent/guardian may choose to have the appeal reviewed at the third and final level. The submission should be addressed to the NIHB Director General, and faxed to the Orthodontic Review Centre.