Content Dental Care

DENTAL Care Content Dental Care 134 How must the professional proceed in order to obtain reimbursement for dental care? 137 Why is the professional/provider asking the client to pay for their service? 138 Reason 1 - The professional/provider refuses to collaborate with Health Canada to receive payment for the services or the professional is unfamiliar with Heath Canada’s reimbursement process. 140 Reason 2 - The client did not indicate their First Nations status to the professional/provider. 141 Reason 3 - Difference in cost between the amount reimbursed by Health Canada and the amount being billed by the professional/provider. 143 Reason 4 - Non-respect for the frequency limits in the client’s file (e.g. not enough time has passed between two treatments). 144 Reason 5 - The dental care being requested is excluded from the program. 145 Frequently Asked Questions DENTAL CARE Since February 2013, preauthorisation for Health Canada’s dental care services is performed by the National Dental Predetermination Centre located in Ottawa. Health Canada’s Dental Care program covers care and services when these are not covered by Quebec’s health insurance plan. Client eligibility is described in the following table. ELIGIBLE CLIENTELE RAMQ NIHB • Children nine years of age or under (ex- • The costs for cleaning, periodontal scaling cludes: cleaning, periodontal scaling and and the application of fluoride and sealants fluoride) for children ages nine years or under • Provincial income security recipients • First Nations members ten years and up (on- and off-reserve) See the Provincial Health Care and • Income security recipients on-reserve Services section The services covered by Health Canada are described in: • The Dental Benefits Guide (appended); • The NIHB information booklet, pages 8 to 14. Certain types of services provided by the Dental Care program must be preauthorised by Health Canada. All requests from professionals/providers are received and authorised by the National Dental Predetermination Centre in Ottawa. Usually, in Quebec, the professionals/providers are quite familiar with how Health Canada ope- rates. However, sometimes problems arise when attempting to access the care and services. This section will enable you to better understand the request processing process for dental care and services. You will also find a list of commonly encountered problems as well as possible solutions in order to address these situations. In this section, the term “professional/provider” includes dentists, dental care specialists (en- dodontists, periodontists, orthodontists, prosthodontists, etc.) and denturologists. CONTENT - Dental Care 133 REGULAR DENTAL CARE REIMBURSEMENT PROCESS HOW MUST THE PROFESSIONAL PROCEED IN ORDER TO OBTAIN REIMBURSEMENT FOR DENTAL CARE? All the professionals/providers who wish to provide services to the First Nations and use the online billing system must be registered/connected to a national electronic system linking them directly to Health Canada. Express Script Canada (ESC) is an organisation that uses an electronic system allowing the professionals/providers to bill Health Canada directly for the treatments provided. ESC is also the organisation responsible for auditing the financial statements and the accuracy of the invoices submitted by the professionals/providers. It has the power to recover money when irregularities are found in the billing. ESC has no power related to the authorisation of dental care and services. It is just the organisation responsible for financial management. If the professional is not registered with ESC, they can contact the toll-free inquiry centre intended for providers (1-888-511-4666) to receive support for the registration steps. GPS • GUIDE TO PROCEDURES FOR ACCESSING HEALTH SERVICES 134 REGULAR REIMBURSEMENT PROCEDURES OF THE PROFESSIONALS/PROVIDERS The professional/provider must seek predetermination for the majority of the dental care services before providing any care or treatment to the client. See important note Predeterminations must be performed by mail only. Once it is mailed, the professional/provider will then obtain a predetermination number to be included on the invoice sent to ESC in order to receive reimbursement from Health Canada. The professional must forward to the National Dental Predetermination Centre: • A Dent-29 form duly completed by the professional/provider; See the appended form. • The x-rays; • Any other diagnostic aid. All the documentation must be transmitted to the following address: National dental predetermination Centre Non-Insured Health Benefits First Nations and Inuit Health Branch Health Canada Postal Locator 1902D 2nd floor, Jeanne Mance building 200, Eglantine Driveway Ottawa (Ontario) K1A 0K9 CONTENT - Dental Care 135 EXCEPTION FOR PREDETERMINATION BY MAIL The only types of dental care that can be predetermined by telephone or fax are den- tures. National Dental Predetermination Centre Telephone: 1-855-618-6291 Fax: 1-855-618-6290 Any other predetermination requests for care and treatment must be sent by mail. IMPORTANT NOTE the predetermination performed by the professional: Predetermination for dental care services is particularly important due to the fact that there are many exceptions and specific types of care that can be approved depending on certain conditions (position of the tooth in the mouth, treatment history, etc.). See NIHB information booklet, pages 8 to 14. It should be noted that if no predetermination is requested from the National Dental Pre- determination Centre, the professional is at-risk of providing services to the patient that will not be eligible for the program and for which all of the costs must be covered by the patient. It is also possible that Health Canada’s reimbursement will be lower than what the professional/provider wishes to charge the client. Note that, at all times, patients must be informed regarding what they will be required to pay before receiving their services. Then the patients can decide whether or not they wish to receive the service. GPS • GUIDE TO PROCEDURES FOR ACCESSING HEALTH SERVICES 136 PROBLEMS RELATED TO DENTAL CARE REIMBURSEMENT WHY IS THE PROFESSIONAL/PROVIDER ASKING THE CLIENT TO PAY FOR THEIR SERVICE? Usually, it is the dental care and services professional/provider who deals directly with Health Canada for predetermination and billing purposes. The client is therefore not required to pay with their own money. However, certain circumstances can cause the professional/provider to ask your client to pay in order to access the health care and services that they need. There are five possible reasons: The professional/provider refuses to collaborate with Health Canada in Reason order to receive payment for the services or the professional is unfamiliar with Health Canada’s reimbursement process. The client did not indicate their First Nations status to the professional/ Reason provider. There is a difference in cost between the amount reimbursed by Health Reason Canada and the amount being billed by the professional/provider (overbilling). Reason Non-respect for the frequency limits in the client’s file (i.e. not enough time has passed between two treatments). Reason The dental care being requested is excluded from the program. CONTENT - Dental Care 137 The professional/provider refuses to collaborate with Health Canada to receive payment for the services or the Reason professional is unfamiliar with Heath Canada’s reimbursement process. SOLUTIONS 1. You can ask the professional/provider to contact the National Dental Predetermina- tion Centre for more information on the billing system (ESC) and the process for ob- taining reimbursement; Health Canada’s National Dental Predetermination Centre: 1-855-618-6291. 2. You can help the client to find another professional/ provider who is willing to collaborate with Health Canada; See the appended list of the professionals/providers by region. 3. Your client can accept to pay the invoice and then seek reimbursement from Health Canada. See important note In this case, the client must forward by mail: • The professional/provider’s original invoice; • A Dent-29 form duly completed by the professional. See the appended form. GPS • GUIDE TO PROCEDURES FOR ACCESSING HEALTH SERVICES 138 All the documentation must be forwarded to the following address (a period of 30 days must be expected for reimbursement). National dental predetermination Centre Non-Insured Health Benefits First Nations and Inuit Health Branch Health Canada Postal Locator 1902D 2nd floor, Jeanne Mance building 200, Eglantine Driveway Ottawa (Ontario) K1A 0K9 IMPORTANT NOTE The predetermination of the dental care by the client. Ideally, the client must seek predetermination from Health Canada’s National Dental Predetermination Centre before their appointment in order to ensure that the services being requested are eligible for reimbursement. If the client does not obtain predetermination, they are at-risk of receiving services that are not included in Health Canada’s Dental Benefits Guide and therefore ineligible for reimbursement. The client will be obligated to pay them completely. CONTENT - Dental Care 139 The client did not indicate their First Nations status to Reason the professional/provider. SOLUTION If the client has already paid the bill, the client can file the claim on their own in order to receive reimbursement. The client must send by mail: See important note • The provider’s original invoice; • A Dent-29 form duly completed by the professional.

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