Dental Benefit Information - Questions and Answers

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What Dental Benefits are covered by the Non-Insured Health Benefits (NIHB) Program?

• Diagnostic services (e.g. examinations or x-rays);
• Preventive services (e.g. cleanings);
• Restorative services (e.g. fillings);
• Endodontics services (e.g. root canals);
• Periodontal services (e.g. deep cleanings);
• Prosthodontic services (e.g. removable dentures);
• Oral surgery services (e.g. removal of teeth);
• Orthodontic services (e.g. braces); and
• Adjunctive services (e.g. general anaesthetics or sedation).

How can I access Dental Benefits under the NIHB Program?

First, you must be an eligible client under the Non-Insured Health Benefits Program. Then, you must be examined by a dental provider who will establish a treatment plan and discuss with you the services that you will require.

The dental provider should tell you what is covered by the NIHB Program, because certain services may need to be pre-approved by the NIHB Program.

If your provider doesn't know whether the service is covered by the NIHB Program, you can obtain that information by contacting the Health Canada regional office, or the National Dental Predetermination Centre (NDPC) for those regions which have been centralized, and asking the dental benefits staff what is and is not covered.

What does "predetermination" mean?

• Predetermination, also known as pre-approval, is the process of obtaining approval in advance. This process involves a review of the case against established NIHB policies, criteria and guidelines before the service is rendered.
• Predetermination or pre-approval is required on certain dental services.
• All cases requiring predetermination must be sent by your dental provider's office to the appropriate Health Canada regional office, or NDPC for review and a coverage decision before treatment begins.

  NDPC address and contact information are as follows:

  National Dental Predetermination Centre
  Non Insured Health Benefits
  First Nations and Inuit Branch, Health Canada
  A.L. 1902D, 2nd Floor, Jeanne Mance Building
  200 Eglantine Driveway, Tunney's Pasture
  Ottawa, ON  K1A OK9
  Toll free phone #:  1-855-618-6291
  Toll free tax #:  1-855-618-6290

• Predetermination is required for all orthodontic services. Requests must be sent to the Orthodontic Review Centre at the following address:

  Orthodontic Review Centre
  Non-Insured Health Benefits
  First Nations and Inuit Health Branch
  Health Canada
  Address Locator 1902C
  2nd Floor, Jeanne Mance Building
  200 Eglantine Driveway
  Ottawa, Ontario
  K1A 0K9

• Predetermination requests must be supported with additional documentation from your dental provider, such as x-rays, supporting rationale, tooth charting, etc. The additional documentation may vary depending on the dental service required.

Who can provide dental benefits?

Dental services must be provided by a licensed dental professional, such as a dentist, dental specialist, or denturist.

Do I have to pay upfront for dental benefits?

The NIHB Program strongly encourages dental providers to bill the NIHB Program directly. The dental provider has an obligation to tell you, as the client, if you will have to pay for services before treatment is started.

Can I continue to see my current dental provider if they do not bill the NIHB Program directly?

Yes, that is your choice. However, it is recommended you contact the Health Canada regional office or NDPC before receiving any dental service to ensure that this particular dental service is eligible for coverage under the NIHB Program.

In such cases, you must pay your provider yourself, and then submit a request with all necessary documentation to the NIHB Program in order to be considered for reimbursement.

Remember that your provider may charge more than the amount that is covered by the NIHB Program, which means that you would not be reimbursed the full amount that you paid.

The request for reimbursement can be submitted to NIHB up to one year from the date on which the services were received.

Do emergency dental services require predetermination?

No. Emergency dental services do not require predetermination.
Emergency services include treatment for acute dental problems and associated examinations, radiographs, procedures for the immediate relief of pain and infection, arresting bleeding, and preliminary care of trauma to the mouth.

My child needs braces. Where can I find more information on NIHB orthodontic services?

For more information about NIHB orthodontic services you can call the Orthodontic Review Centre at:
1-866-227-0943.

Information on orthodontic services can also be found on Health Canada's NIHB website.

Is there an Appeal Process when a benefit has been denied?

A client, parent, legal guardian or representative may initiate an appeal when a benefit has been denied by the NIHB Program.

For a case to be reviewed as an appeal, a signed note or letter from the client, parent or legal guardian, accompanied by supporting information from the dental provider (e.g. dentist) must be submitted to the NIHB Program. There are three levels of appeal available.

Some dental procedures are exclusions of the NIHB Program and are not eligible for appeal (e.g. implants).

For more information on the appeal process please refer to the Appeal Procedures section or contact the Health Canada regional office or NDPC.

Where can I get more information about the NIHB Dental Benefit?

For more information about Dental Benefits you can call the nearest Health Canada regional office, NDPC, or under the Benefit Information section of Health Canada's NIHB website at: www.healthcanada.gc.ca/nihb

How do I contact the Health Canada regional office in my area?

See Health Canada regional offices.