Orthodontic Bulletin

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August 2004

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The Non-Insured Health Benefits (NIHB) Program provides supplementary health benefits, including dental treatment, for registered First Nations and recognized Inuit throughout Canada. Visit our Web Site at:
http://www.hc-sc.gc.ca/fnihb/nihb

The purpose of this bulletin is to:

• clarify the orthodontic benefits funded under the NIHB Program;  
• announce there will now be no age restriction for dental-facial anomalies;  
• introduce a new standardized option for final payment (P1400).  

Funding Criteria

NIHB is a publicly funded Program that covers a limited range of orthodontic benefits for eligible First Nations and Inuit. Clients must meet the clinical criteria and guidelines established by the NIHB Program for their orthodontic treatment to be funded.

A severe and functionally handicapping malocclusion is characterized as:

• dento-facial anomalies such as cleft lip and palate. No age restriction.
• a combination of marked skeletal discrepancy (AP, transverse, and/or vertical) and a marked dental discrepancy (AP, transverse, and/or vertical), with associated severe functional limitations. The purpose of the treatment must be to resolve the identified discrepancies. Age restriction of under 18 years.

Note: The complete list of NIHB Guidelines for Comprehensive Orthodontic Treatment can be found in the Dental Practitioners Information Kit (DPIK) and in the NIHB Orthodontic Bulletin dated June 2002. Both documents can be found on the NIHB Web site.

Orthodontic Predetermination Submission Requirements

The NIHB Program can only determine if a client meets the Program's funding criteria by reviewing the client's records and treatment plan. Health Canada relies on orthodontists to help individuals submit the required information. Unfortunately, the Program cannot provide orthodontic treatment funding if this information is not submitted for review.

Orthodontic treatment funding requests submitted to the Orthodontic Review Centre (ORC) must include:

1. A Narrative

• identify the condition for which the treatment is being requested.
• explain diagnosis and prognosis.  
• note basic treatment completed to date; patient's oral hygiene status; and motivation.  
• include a detailed treatment plan.  
• estimate duration of active and retention phases of treatment and cost(s).  
• identify additional relevant supporting information.

The above information can be submitted on either a NIHB Orthodontic Summary Sheet; CAO Standard Information Form; or on the Orthodontist's letterhead.

2. Complete Diagnostic Records

• diagnostic orthodontic models (trimmed)  
• Cephalometric: radiograph(s) and tracing  
• Photographs: 3 intra oral and 3 extra oral  
• Panoramic radiograph or full mouth survey

3. A Completed NIHB Dent-29 Form

for more information refer to Dental Practitioners Information Kit (DPIK)

Interceptive Treatment Submission Requirements

As a prevention initiative, funding will be considered for the provision of interceptive orthodontic treatment (80000 series procedures) in the mixed dentition phase of dental development.

NIHB requires:

• Diagnostic records including working models and a panoramic radiograph.  
• A narrative indicating treatment objective(s), a treatment plan, projected active treatment time and anticipated fee.  

Orthodontic Payment Codes or Specific Wording 

As per the May 2000 National Agreement between the Canadian Association of Orthodontists (CAO), Health Canada and the Assembly of First Nations, payment codes or the specific wording indicated below must be used when submitting a claim.

Payment Structure for Comprehensive Orthodontic Treatment:

• P1000 or Examination  
• P1100 or Diagnostic Records  
• P1101 or Diagnostic Records and Examination  
• P1200 or Initial Payment - initiation of treatment. You will be reimbursed 30% of treatment fee.  
• P1300 or Incremental Payment - 9 months after comprehensive orthodontic treatment is initiated. You will be reimbursed 25% of treatment fee.  
• P1300 or Incremental Payment - 15 months after initiation of comprehensive orthodontic treatment. You will be reimbursed 25% of treatment fee.  
• P1400 or Final Payment - when active orthodontic treatment has been completed. You will be reimbursed 20% of orthodontic fee.

New - Orthodontic Final Payment Form

This one page form will satisfy the need for a National Standard for final payment and reduce administration requirements. It can be submitted by the provider upon completion of orthodontic treatment and attached to the Dent-29 Form indicating "post approval". With this form, pre/post orthodontic treatment records are not required to be submitted to obtain final payment (P1400). A copy of this form is enclosed. Additional forms can be obtained by contacting the ORC.

Claim Submission Requirements to First Canadian Health (FCH)

Health Canada prefers that providers bill the NIHB Program directly for services so there are no upfront charges to clients. However, dental providers have the choice to request the patient pay and seek reimbursement from the Program.

Provider Reimbursement

• indicate 'claim' on Dent-29 form  
• complete a Dent-29 form

Client Reimbursement

• indicate 'claim' on Dent-29 form  
• complete a Dent-29 form  
• include the original receipt. This is required as proof of payment
• Send claim to the Orthodontic Review Centre for processing

Please remember to forward all orthodontic treatment requests directly to the Orthodontic Review Centre and not to the NIHB Regional Offices. Sending requests to the wrong office will result in significant processing delays.

Orthodontic Review Centre
Non-Insured Health Benefits
First Nations and Inuit Health Branch
Health Canada
55 Metcalfe Street, 5th Floor
Postal Locator 4005A
Ottawa, Ontario
K1A 0K9

Toll-Free Phone: 1-866-227-0943
Toll-Free Fax: 1-866-227-0957

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