Appealing a decision under the NIHB program
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Service description
Find out how to appeal a denied benefit claim through the Non-Insured Health Benefits (NIHB) program.
Who can appeal
When coverage for a benefit through the Non-Insured Health Benefit (NIHB) program is denied, you may appeal the decision as the:
- client
- parent or legal guardian
- representative of the client
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
- provide supporting information from a health care provider or prescriber
Submit an appeal for drug benefits
When you appeal a drug benefit, the documents you provide must include the:
- condition for which the drug is being requested
- diagnosis and prognosis (including what other drugs have been tried)
- relevant diagnostic test results
- reason for the proposed treatment
- any additional supporting information, such as case notes from your health provider
Where to send your drug benefits appeal
You must mail or fax all documents to the Non-Insured Health Benefits (NIHB) program headquarters. Email requests are not accepted, to ensure client confidentiality.
When mailing, the appeal letter and supporting documents should be placed in a double-envelope.
- The inner envelope should contain the appeal letter and supporting documents. It should be sealed and have "APPEAL—CONFIDENTIAL" clearly written on the outside. It should then be placed inside a second envelope.
- The second envelope should have the program headquarters address written on the outside.
Your letter of appeal and supporting documents are to be addressed to a different program official at each appeal level. The information will be reviewed at each level by a different health professional that will provide recommendations to the program.
Drugs or products that are identified as exclusions under the NIHB program will not be considered for appeal.
Level 1 appeal
To begin the appeal process, you must address all documents to the Manager, Pharmacy Policy Development Division.
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 should include any additional or new supporting information from your health service provider or prescriber. You must address all documents to the Director, Benefit Management and Review Services Division.
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 should include any additional or new supporting information from your health service provider or prescriber. You must address all documents to the Director General, NIHB program.
Submit an appeal for dental benefits including orthodontics
When you appeal a dental service, the documents you provide must include:
- one of the following completed forms:
- Canadian Dental Association (CDA) Standard Dental Claim Form
- Non-Insured Health Benefits (NIHB) Dental Claim Form (DENT-29)
- Computer generated claim form (specific to your provider office)
- Association des chirurgiens dentistes du Québec (ACDQ) Dental Claim and Treatment Plan Form
- a comprehensive treatment plan from the treating and/or referring dentist or specialist
- the plan must indicate all completed treatment and pending treatment needs, including services that are:
- surgical
- restorative
- endodontic
- periodontal
- orthodontic
- prosthodontic
- the plan must indicate all completed treatment and pending treatment needs, including services that are:
- current (within the last 12 months) conventional or digital radiographs (X-rays), including:
- periapical and bitewing
- panoramic (if available)
- a record of all missing teeth
- any or all of the following information:
- periodontal charting
- periodontal assessment
- periodontal screening and recording (PSR)
- periodontal tooth specific measurements (6 sites per tooth), where applicable
- all pertinent clinical findings and notes supporting the request
- a dated appeal letter signed by the client, parent or legal guardian, or client's representative, which includes the client's:
- name
- date of birth
- identification (ID) number
When you appeal an orthodontic service, the documents you provide must include:
- one of the following completed forms:
- Canadian Association of Orthodontists (CAO) Standard Orthodontic Information Form
- CDA Standard Dental Claim Form
- ACDQ Dental Claim and Treatment Plan Form
- Computer generated claim form (specific to your provider office)
- NIHB Dental Claim Form (DENT-29)
- pre-treatment diagnostic records including the following:
- diagnostic orthodontic models (in any of the formats below)
- physical models: either trimmed stone models or 3D–printed models with the centric occlusion position marked
- photo models where overjet, overbite and labio-lingual spread are documented in millimeters (mm)
- cephalometric radiograph with associated scale for calibration
- photographs: frontal and profile views; intra-oral depicting right and left occlusal relationship as well as anterior views
- panoramic radiograph
- diagnostic orthodontic models (in any of the formats below)
Note: Written confirmation of client's oral health status from the general practitioner may be requested upon the review of the case.
- all objective clinical medical/dental evidence supported with appropriate documentation for each of the following four (4) areas:
- principal diagnosis and significant associated diagnoses
- clinical significance or functional impairment related to any clinical signs or symptoms
- specific services to be rendered and anticipated time for achievement of goals
- any other relevant documentation available which may assist NIHB in making a determination of the severe and functionally handicapping malocclusion
Note: Subjective statements submitted must be substantiated by objective clinical medical/dental evidence and supported with appropriate documentation.
- a dated appeal letter signed by the client, parent or legal guardian, or client's representative, is required which includes the client's:
- name
- date of birth
- identification (ID) number
Where to send your dental benefits (including orthodontics) appeal
You must mail all documents to the NIHB Dental Predetermination Centre. Email requests will not be accepted, to ensure client confidentiality. Please label your envelope "APPEAL—CONFIDENTIAL" and address it either to:
- NIHB Dental Predetermination Centre (Dental Services) for dental appeals, or
- NIHB Dental Predetermination Centre (Orthodontic Services) for orthodontic appeals
Your letter of appeal and supporting documents are to be addressed to a different program official at each appeal level. The information will be reviewed at each level by a different health professional that will provide recommendations to the program. Services that are identified as exclusions under the NIHB program will not be considered for appeal.
Level 1 appeal
To begin the appeal process, you must address all documents to the Director, Dental Policy Development Division.
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 should include:
- the initial documentation submitted
- any additional or new supporting information from your dental or orthodontic service provider
You must address all documents to the Director, Benefit Management and Review Services Division.
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 should include:
- the initial documentation submitted
- any additional or new supporting information from your dental or orthodontic service provider
You must address all documents to the Director General, NIHB program.
Orthodontic appeals
To be eligible for an appeal of orthodontic benefits, a predetermination submission must have been made before the client turned 18 years old. There is no age limit for predetermination submission for craniofacial anomaly cases. The review for all appeal levels will be based on current records obtained before the start of orthodontic treatment. If you start an orthodontic treatment following a denial for service coverage, you may still access the appeal process. You can appeal as long as:
- the treatment was predetermined before the age of 18
- all 3 levels of appeal are completed before the age of 19
There is no age limit to appeal for craniofacial anomaly cases. You must have submitted all required documents for each appeal level within a year from the date of service or date of insertion of orthodontic appliance/braces.
Submit an appeal for other eligible benefits
Other eligible benefits for appeal include:
- vision care
- medical transportation
- medical supplies and equipment
- mental health counselling
When you appeal any of these benefits, the documents you provide must include the:
- condition for which the benefit is being requested
- diagnosis and prognosis (including what other options have been tried)
- relevant test results
- reason for the proposed treatment
- any additional supporting information, such as case notes from your health provider
Where to send your appeal
You must mail all documents to the Non-Insured Health Benefits (NIHB) program (see below level of appeal for mailing instructions) in a double-envelope:
- The inner envelope should contain the appeal letter and supporting documents. It should be sealed and have "APPEAL—CONFIDENTIAL" clearly written on the outside. It should then be placed inside a second envelope.
- The outer envelope should be addressed to the appropriate regional office.
Email requests will not be accepted, to ensure client confidentiality.
Your letter of appeal and supporting documents are to be addressed to a different program official at each appeal level. The information will be reviewed at each level by a different health professional that will provide recommendations to the program.
Services that are identified as exclusions under the NIHB program will not be considered for appeal.
Level 1 appeal
To begin the appeal process, you must address all documents to the Regional Manager, NIHB program.
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 should include any additional or new supporting information from your health service provider or prescriber. You must address all documents to the Regional Executive, First Nations and Inuit Health Branch.
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 should include any additional or new supporting information from your health service provider or prescriber. You must address all documents to the Director General, NIHB program headquarters.
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:
- your specific health needs
- medical justification
- collected research
- availability of other options
- Non-Insured Health Benefit program policy
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. We always try 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:
- NIHB regional office in your area for all benefits, except as noted below:
- NIHB Dental Predetermination Centre for dental and orthodontic services
- NIHB Drug Exception Centre for medications