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:

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 an appeal for drug benefits

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

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:

When you appeal an orthodontic service, the documents you provide must include:

Note: Written confirmation of client's oral health status from the general practitioner may be requested upon the review of the case.

Note: Subjective statements submitted must be substantiated by objective clinical medical/dental evidence and supported with appropriate documentation.

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:

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:

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:

When you appeal any of these benefits, the documents you provide must include the:

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:

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:

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