Orthodontic Services Information - Questions and Answers

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Is all orthodontic treatment covered under NIHB?

Not all orthodontic treatment is covered under the NIHB Program. Eligible clients must meet all of the clinical criteria and guidelines established by the NIHB Program for their orthodontic treatment to be considered for coverage. Eligibility for coverage for orthodontic treatment is determined based on the severity of the client's oral condition.

The NIHB Program provides coverage for three (3) types of orthodontic treatment modalities:

1. Comprehensive treatment for severe and functionally handicapping malocclusion;
2. Limited treatment for severe and functionally handicapping malocclusion;
3. Interceptive and/or preventive treatment for severe and functionally handicapping malocclusion.

The NIHB Program does not provide coverage for orthodontic treatments to address:

• Facial esthetics;
• Psychological purposes (e.g. self-esteem cases);
• Temporomandibular disorders;
• Non-handicapping malocclusion (e.g. crossbite relationships without an associated significant functional shift); or
• Skeletal discrepancies with a functional pattern.

How do I know if the orthodontic treatment my dental provider recommends will be covered?

The NIHB Program will determine if a client's treatment request meets the NIHB Program's established criteria and guidelines by reviewing the client's records and treatment plan. The NIHB Program encourages dental providers to assist clients in submitting all required information. Without the client's dental records, the Program is unable to conduct a review. Once the case has been reviewed, the NIHB Program will notify the client/parent/legal guardian via mail of the Program's decision.

My treatment plan has been accepted by the NIHB Program for coverage. Who pays for these services?

The NIHB Program encourages dental providers to bill the Program directly so there are no upfront charges to clients. However, dental providers make their own decisions on how to administer their offices and what payment policies they put in place, therefore, they may request that the client pay and subsequently seek reimbursement from the Program. In these situations, dental providers should explain their office policies to clients prior to rendering treatment.

What are the dental provider's responsibilities?

Your dental provider will give you information on available treatment options appropriate to your orthodontic care needs, regardless of the nature and extent of your dental plan coverage. It is important to understand that not all orthodontic treatment recommended by your dental provider will be covered by the NIHB Program.

Your dental provider will assist you by sending all of the required information to the Program to review your case.

Your dental provider should also clearly explain any financial responsibilities related to the orthodontic treatment. In the case of client reimbursement, the dental provider should assist you in obtaining reimbursement.

My treatment plan has been accepted by the NIHB Program for coverage. How do I seek reimbursement from the Program for the cost of these services if my provider does not bill the Program directly?

Health Canada encourages dental providers to bill the NIHB Program directly for services so there are no upfront charges to clients. However, if you must pay and seek reimbursement from the NIHB Program, the following are required:

• Original receipt(s) for proof of payment - please note that credit card/debit (Interac) slips are not acceptable form of proof of payment;
• Sign and complete all applicable sections of the NIHB Client Reimbursement Request Form or a  Dent-29 Form; and
• One of the following forms:
  • Association des Chirurgiens Dentistes du Québec Dental Claim and Treatment Plan Form
  • Standard Dental Claim Form
  • Canadian Association of Orthodontics Information Form.
• A detailed statement or explanation of benefits from your other health plan(s)/program(s), if applicable. This document explains what has been covered/paid by the client's other health plan(s)/program(s).

Please note: Original receipts are not required when submitting the detailed statement or explanation of benefits as the other health plan(s)/program(s) require the original. In such cases, a copy of the original receipt is acceptable.

The new NIHB Client Reimbursement Request Form can be found and downloaded by accessing the following link: http://www.hc-sc.gc.ca/fniah-spnia/nihb-ssna/benefit-prestation/form_reimburse-rembourse-eng.php

The  Dent-29 Claim Form can be found and downloaded by accessing the following link: http://www.provider.esicanada.ca/dentists.html

The information listed must be submitted to Health Canada's Orthodontic Review Centre within one year from the date on which the service was provided.

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

For any questions or additional information, you can contact the Orthodontic Review Centre directly at:

Toll-free phone: 1-866-227-0943
Toll-free fax: 1-866-227-0957