Appealing a decision under the NIHB program

Find out how to appeal a denied benefit through the Non-Insured Health Benefits (NIHB) program.

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Who can appeal

When coverage for a benefit through the Non-Insured Health Benefits (NIHB) program is denied, you may appeal the decision as:

If you are unable to request an appeal yourself, you may authorize someone to act as a representative on your behalf. This authorization must be in writing.

To begin the appeal process, you must submit a signed letter to the NIHB program.

There are 3 levels of appeal. Your letter of appeal and supporting documents will be considered by a different program official at each appeal level. The information will also be reviewed at each level by a different health professional who will provide recommendations to the program.

Items that are listed as exclusions cannot be considered for appeal.

Submit an appeal for drug benefits

When you appeal a drug benefit, the documents you provide must include:

You can submit an appeal either:

Email requests are not accepted.

Level 1 appeal

To begin the appeal process, submit your appeal and supporting documents to the attention of:

Director, Pharmacy Policy Development Division
Address locator: 1909D
Ottawa ON K1A 0K9
Fax: 1-613-954-5265

Or, submit online through your secure NIHB client web account, available on the Express Scripts Canada NIHB provider and client website.

Level 2 appeal

You may choose to have the appeal reviewed at the level 2 stage if:

  • you do not agree with the level 1 appeal decision
  • there is new information available for review since the last appeal

The submission must include any additional or new supporting information from your health service provider or prescriber.

Submit your level 2 appeal and supporting documents to the attention of:

Director, Benefit Management and Review Services Division
Address locator: 1902D
Ottawa ON K1A 0K9
Fax: 1-877-789-4379

Or, submit online through your secure NIHB client web account, available on the Express Scripts Canada NIHB provider and client website.

Level 3 appeal

You may choose to have the appeal reviewed at the final level 3 stage if:

  • you do not agree with the level 2 appeal decision
  • there is new information available for review since the last appeal

The submission must include any additional or new supporting information from your health service provider or prescriber.

Submit your level 3 appeal and supporting documents to the attention of:

Director General, NIHB Program
Address locator: 1909A
Ottawa ON K1A 0K9
Fax: 1-613-954-5265

Or, submit online through your secure NIHB client web account, available on the Express Scripts Canada NIHB provider and client website.

Submit an appeal for dental benefits, including orthodontics

To submit an appeal for a dental or orthodontic service, refer to the NIHB Dental Benefits Guide, Appendix D: Appeal process. You can submit an appeal by mail, or online through your secure NIHB client web account, available on the Express Scripts Canada NIHB provider and client website.

Email requests are not accepted.

Submit an appeal for medical supplies and equipment, vision care or mental health counselling benefits

When you submit an appeal for these benefits, you can provide any additional supporting information, such as documentation from your health provider, that was not provided during the initial claim or prior approval process.

Where to send your appeal

Mail or fax all documents to the addresses in this section.

Or, submit an appeal online through your secure NIHB client web account, available on the Express Scripts Canada NIHB provider and client website.

Email requests are not accepted.

Level 1 appeal

To begin the appeal process, submit your appeal and supporting documents to the attention of:

Regional Director, NIHB Program
Mail address and fax can be found here: NIHB regional office.

Or, submit online through your secure NIHB client web account, available on the Express Scripts Canada NIHB provider and client website.

Level 2 appeal

You may choose to have the appeal reviewed at the level 2 stage if:

  • you do not agree with the level 1 appeal decision
  • there is new information available for review since the last appeal

The submission must include any additional or new supporting information from your health service provider or prescriber.

Submit your level 2 appeal and supporting documents to the attention of:

Regional Executive, First Nations and Inuit Health Branch
Mail address and fax can be found here: FNIHB Regional Executives

Or, submit online through your secure NIHB client web account, available on the Express Scripts Canada NIHB provider and client website.

Level 3 appeal

You may choose to have the appeal reviewed at the final level 3 stage if:

  • you do not agree with the level 2 appeal decision
  • there is new information available for review since the last appeal

The submission must include any additional or new supporting information from your health service provider or prescriber.

Submit your level 3 appeal and supporting documents to the attention of:

Director General, NIHB Program
Address locator: 1909A
Ottawa ON K1A 0K9
Fax: 1-613-954-5265

Or, submit online through your secure NIHB client web account, available on the Express Scripts Canada NIHB provider and client website.

Submit an appeal for medical transportation benefits

When you submit an appeal, you can provide any additional supporting information, such as documentation from your health provider that were not provided during the initial claim process.

Where to send your appeal

You can mail or fax all documents to your NIHB regional office.

Email requests are not accepted.

Medical transportation benefits are not processed by Express Scripts Canada, so these can't be submitted through your NIHB client web account.

Level 1 appeal

To begin the appeal process, submit your appeal and supporting documents to the attention of:

Regional Director, NIHB Program
Mail Address and fax can be found here: NIHB regional office

Level 2 appeal

You may choose to have the appeal reviewed at the level 2 stage if:

  • you do not agree with the level 1 appeal decision
  • there is new information available for review since the last appeal

You must provide any additional or new supporting information, such as documentation from your health provider. Submit your level 2 appeal and supporting documents to the attention of:

Regional Executive, First Nations and Inuit Health Branch
Mail Address and fax can be found here: FNIHB Regional Executives

Level 3 appeal

You may choose to have the appeal reviewed at the final level 3 stage if:

  • you do not agree with the level 2 appeal decision
  • there is new information available for review since the last appeal

You must provide any additional or new supporting information, such as documentation from your health provider.

Submit your level 3 appeal and supporting documents to the attention of:

Director General, NIHB Program
Address locator: 1909A
Ottawa ON K1A 0K9
Fax: 1-613-954-5265

After you submit your appeal

Indigenous Services Canada aims to send clients a written explanation of the decision within 30 business days, 80% of the time, under normal circumstances, after receiving completed appeal documents.

The decision will be made based on:

The 30 business day period starts from the date that the NIHB program receives the appeal request and ends when the request is settled. The NIHB service standard applies for approved and denied appeals requests (completed cases), as well as for approval requests put on hold (incomplete cases) due to missing information. For on-hold appeal requests, the 30 business day period will restart when the NIHB program receives the new information.

Normal circumstances refer to the program's available resources, which have been put in place based on the expected level of demand for regular day-to-day operations.

The program may not be able to meet the service standard in special circumstances such as: higher than expected levels of demand, prolonged holiday periods (such as Christmas and New Year), labour disruptions, natural disasters such as flood or fire, or technical issues such as equipment, software, telecommunications or power failure. NIHB strives to resume normal operations as soon as possible following such a disruption.

At any time, you can direct questions regarding the status of your appeal to the:

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