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

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.

Appeal Process for Orthodontic Services

In order for a client to be eligible for an appeal for orthodontic services, a Predetermination (PD) submission must have been received by NIHB's Orthodontic Review Centre (ORC) prior to client's 18th birthday.

If coverage for orthodontic treatment has been denied, the client, the parent or the legal guardian of the client has the right to appeal the decision. All three levels of appeal must be accompanied with the supporting documentation provided by the dental practitioner and be completed prior to the client's 19th birthday.

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

If a client decides to start an orthodontic treatment after the request for coverage was denied by the NIHB Program, the client may still access the appeal process, as long as the treatment was predetermined before the age of 18, and all levels of appeal are completed before the age of 19.  Please note that if a client chooses to start an orthodontic treatment following a denial for coverage of orthodontic services under the NIHB Program, all three (3) levels of appeal must be initiated within one year period from the date of service/ insertion date.

The following supporting documentation must be provided to NIHB's ORC for consideration of an appeal:

• Diagnostic Orthodontic Models trimmed in centric occlusion. If photographs of models are submitted, the NIHB Program reserves the right to ask for the original stone models.
• Cephalometric radiograph and tracing.
• Panoramic radiograph or Full-Mouth-Survey (FMS).
• Photographs: three (3) intraoral and three (3) extraoral.
• Treatment plan, estimated duration of active and retention phases of treatment and costs submitted either on a NIHB Orthodontic Summary Sheet, Canadian Association of Orthodontists (CAO) Standard Orthodontic Information Form or letter with the provider's letterhead.
• Completed NIHB Dental Claim Form (Dent-29), CAO Standard Orthodontic Information Form, Standard Dental Claim Form, Association des chirurgiens dentistes du Québec (ACDQ) Dental Claim and Treatment Plan Form, or computer generated form.
• Client/Parent/Guardian dated appeal letter with signature (must include client name, date of birth, band, and family number). 

Requests for updated diagnostic records must be predetermined and supported with a written rationale in order to be considered for coverage.

Level 1 Appeal:
The client/parent/guardian must initiate the appeal process and address their submission to the Director, Benefit Review Services Division, and forward their documentation to the ORC.

Level 2 Appeal:
If the client/parent/guardian does not agree with the Level 1 appeal decision, they may initiate the second level of appeal. The submission should be addressed to the Director, Benefit Management Division, and the documentation forwarded to the ORC.

Level 3 Appeal:
If the client/parent/guardian does not agree with the Level 2 appeal decision, they may initiate the third and final level of appeal. The submission should be addressed to the NIHB Director General, and the documentation forwarded to the ORC.

At each level of the appeal process, cases are reviewed by a different orthodontist and the client/parent/guardian will be provided with a written explanation of the decision taken.

The ORC address can be found at www.hc-sc.gc.ca/contact/fniah-spnia/fnih-spni/nihbpa-ssnaap-eng.php#orc.