Communication to all NIHB General Practitio ners ......and criteria of dental services eligible...

April 24, 2020

Communication to all NIHB General Practitioners & Specialists in Ontario

Effective March 15, 2020, NIHB has expanded its coverage during the COVID19 pandemic to include consultation by phone or other virtual methods to facilitate the emergency management and triage of clients’ acute oral health care needs. Procedure code 05201 has been added as an eligible service under Schedule A (does not require predetermination) on a temporary basis for the duration of the COVID19 pandemic. Providers will be notified in advance when this procedure code is no longer eligible.

Schedule A 0.0 Diagnostic

Procedure Code Description GP/SP Fee Schedule Type

05201

Consultation with client for the emergency management and triage of clients’ acute oral health care needs by phone or other virtual methods

$49.90 Schedule A

For further information or questions, please contact the Provider Claims Processing Call Centre at 1-888-511-4666.

Thank you.

ONTARIO NIHB Regional Dental Benefit Grid General Practitioners and Specialists

Effective Date April 1, 2020

• The coverage of dental services provided through the NIHB Program will be reimbursed in

accordance with the terms and conditions of the Program.

• Schedule B Procedures require Predetermination.

• Please refer to the NIHB Dental Benefits Guide for further information on policies, guidelines and criteria of dental services eligible under the NIHB Program.

• Please refer to the NIHB Dental Claims Submission Kit for further information on terms and

conditions for submitting a claim under the NIHB Program. • Specialists are compensated at specialist rates for selected procedures within their

specialty. For all other procedures, Specialists are compensated at General Practitioners’ rates.

Should you have any questions, please contact the Provider Claims Processing Call Centre at 1-888-511-4666.

ONTARIONIHB Regional Dental Benefit Grid

General Practitioners and SpecialistsSCHEDULE A

SCHEDULE A (GP/SP) Ontario NIHB Regional Dental Benefit Grid (Effective Date: April 1, 2020)Version 1.0 Page 1 of 8

Code Lab GP Anest Endo O. Med O. Path Ortho Paed Perio Pros Radio

01101 $66.75 $159.1301102 $100.15 $159.13

01103 $133.56 $161.50

01201 $29.37 $40.28

01202 $30.41 $36.81

01204 $65.76 $65.76 $65.76 $65.76 $78.91 $65.76 $65.76

01205 $65.76 $65.76 $65.76 $65.76 $78.91 $65.76 $65.76

01402 $56.49 $56.4901502 $80.9801503 $49.2301702 $80.9801802 $80.98

02101 $117.49 $117.49 $117.49 $117.49 $117.49 $117.4902102 $126.64 $126.64 $126.64 $126.64 $126.64 $126.6402121 $90.54 $90.54 $90.54 $90.54 $90.54 $90.5402122 $97.25 $97.25 $97.25 $97.25 $97.25 $97.2502123 $103.55 $103.55 $103.55 $103.55 $103.55 $103.5502124 $110.28 $110.28 $110.28 $110.28 $110.28 $110.2802125 $116.53 $116.53 $116.53 $116.53 $116.53 $116.53

02111 $25.66 $25.66 $25.66 $25.66 $25.66 $25.6602112 $31.34 $31.34 $31.34 $31.34 $31.34 $31.3402113 $38.03 $38.03 $38.03 $38.03 $38.03 $38.0302114 $42.87 $42.87 $42.87 $42.87 $42.87 $42.8702115 $51.51 $51.51 $51.51 $51.51 $51.51 $51.5102116 $57.96 $57.96 $57.96 $57.96 $57.96 $57.96

0.0 DIAGNOSTIC0.1 EXAMINATIONSMaximum eligibility of examinations: ages 17+: up to 3 in any 12 months; under 17: up to 4 in any 12 months. Frequency limitations take into account overall interaction between various examination services rendered by same provider, different providers within the same office or different office, and their eligibility period.Specialty complete and Specialty limited examinations (performed by specialists only) will not count against the eligible maximum examinations allowable.Complete Oral Examination and Diagnosis1 in any 60 months - when a complete examination is provided, it replaces the recall and the new patient limited examination for the respective eligible period.

Intraoral Radiographs (1-10 films)Includes periapical, bitewing and occlusal radiographs.10 in any 12 months

New Patient Limited1 in a lifetime, with same provider or different provider in the same office1 in any 12 months, with different provider in a different office

Primary and Mixed Dentition

Permanent DentitionEligible only for clients age 12 and older.

Emergency Examination1 in any 12 months

Recall ExaminationAge 17+: 1 in any 12 months; under age 17: 1 in any 6 months

Specific Examination1 in any 12 months

Specialist Examination and Diagnosis - Limited1 in any 12 months/specialty (with GP referral and justification for the referral)

Intraoral Periapical Radiographs (11-15 films), Complete Series1 in any 60 monthsPeriapical Radiographs (11-15 films), Complete Series, and any combination of intraoral radiographs (periapicals, bitewings and occlusal) exceeding 10 films, are not to be covered in conjunction with a panoramic radiograph for the time period (60 months).

0.2 RADIOGRAPHS





02117 $64.63 $64.63 $64.63 $64.63 $64.63 $64.6302118 $71.28 $71.28 $71.28 $71.28 $71.28 $71.2802119 $77.52 $77.52 $77.52 $77.52 $77.52 $77.5202120 $84.27 $84.27 $84.27 $84.27 $84.27 $84.2702131 $30.41 $30.41 $30.41 $30.41 $30.41 $30.4102132 $38.01 $38.01 $38.01 $38.01 $38.01 $38.0102141 $25.66 $25.66 $25.66 $25.66 $25.66 $25.6602142 $31.34 $31.34 $31.34 $31.34 $31.34 $31.3402143 $38.03 $38.03 $38.03 $38.03 $38.03 $38.0302144 $42.87 $42.87 $42.87 $42.87 $42.87 $42.87

02601 $59.87 $59.87 $59.87 $59.87 $59.87 $59.87

04311 L $71.20 $85.44 $85.44 $85.44 $81.00 $85.4404312 L $71.20 $85.44 $85.44 $85.44 $81.00 $85.4404313 L $74.55 $89.46 $89.46 $89.46 $89.46 $89.4604314 L $74.55 $89.46 $89.46 $89.46 $89.46 $89.4604315 L $71.20 $85.44 $85.44 $85.44 $81.00 $85.4404321 L $153.79 $184.55 $184.55 $184.55 $174.00 $184.5504322 L $153.79 $184.55 $184.55 $184.55 $174.00 $184.5504323 L $99.82 $119.78 $119.78 $119.78 $119.78 $119.78

11101 $15.49 $15.49 $15.49 $15.4911107 $7.75 $7.75 $7.75 $7.75

11111 $57.00 $57.00 $68.40 $57.0011112 $114.00 $114.00 $136.80 $114.0011113 $171.00 $171.00 $205.20 $171.0011114 $228.00 $228.00 $273.60 $228.0011117 $29.00 $29.00 $34.80 $29.00

12111 $7.00 $7.00 $7.0012112 $25.63 $25.63 $25.63

12113 $29.00 $29.00 $29.00

13401 $29.00 $37.2413409 $17.00 $20.5413411 $45.18 $54.2213419 $35.14 $42.17

1.0 PREVENTION

0.3 LABORATORY TESTS

Panoramic1 in any 60 months; up to 3 in a lifetimeNot to be covered in conjunction with Periapical Radiographs (11-15 films), Complete Series, and any combination of intraoral radiographs (periapicals, bitewings and occlusal) exceeding 10 films for the time period (60 months).

Topical FluorideIncludes Fluoride Varnish and other Topical Fluoride treatments.Age 17+: 1 in any 12 months; under age 17: 1 in any 6 months.

PolishingAge 17+: 1 time in any 12 months; under age 17: 1 time in any 6 months. Note that 1 time counts either for one unit or for 1/2 unit.

Sealants/Preventive ResinsEligible only for clients 17 years of age and under, on the occlusal surface of permanent molars (16, 26, 36, 46, 17, 27, 37, 47), bicuspids (14, 15, 24, 25, 34, 35, 44, 45); and on the lingual surface of permanent maxillary incisors (11, 12, 21, 22), where surfaces are unrestored.There is a lifetime limit of 2 sealants/preventive resins restorations per eligible tooth.

Fluoride Varnish

ScalingAge 0 to 11: 1 unit in any 12 months in combination with root planing;Age 12 to 16: 2 units in any 12 months in combination with root planing;Age 17+: 4 units in any 12 months in combination with root planing;Predetermination is required for additional units.





20111 $102.18 $102.18 $122.6220119 $102.18 $102.18 $122.6220121 $102.18 $102.18 $122.6220129 $102.18 $102.18 $122.6220131 $30.10 $30.10 $36.1220139 $30.10 $30.10 $36.12

21111 $102.18 $122.6221112 $136.58 $163.9021113 $153.28 $183.9421114 $184.82 $223.5521115 $184.82 $223.5521121 $102.18 $122.6221122 $136.58 $163.9021123 $153.28 $183.9421124 $184.82 $223.5521125 $184.82 $223.5521211 $102.18 $102.18 $122.62 $102.1821212 $136.58 $136.58 $163.90 $136.5821213 $153.28 $153.28 $183.94 $153.2821214 $222.98 $222.98 $267.58 $222.9821215 $222.98 $222.98 $267.58 $222.9821221 $102.18 $102.18 $122.62 $102.1821222 $169.98 $169.98 $203.98 $169.9821223 $187.66 $187.66 $225.19 $187.6621224 $280.88 $280.88 $314.00 $280.8821225 $288.09 $288.09 $345.71 $288.0921231 $102.18 $102.18 $122.62 $102.1821232 $136.58 $136.58 $163.90 $136.5821233 $153.28 $153.28 $183.94 $153.2821234 $222.98 $222.98 $267.58 $222.9821235 $222.98 $222.98 $267.58 $222.9821241 $102.18 $102.18 $122.62 $102.1821242 $169.98 $169.98 $203.98 $169.9821243 $187.66 $187.66 $225.19 $187.6621244 $280.88 $280.88 $314.00 $280.8821245 $288.09 $288.09 $345.71 $288.0921401 $21.77 $27.40 $27.2021402 $35.15 $45.72 $42.7321403 $46.85 $56.70 $56.2221404 $60.91 $76.15 $73.0921405 $79.63 $96.37 $95.5622201 $184.82 $223.55 $184.8222202 $184.82 $223.55 $184.8222211 $184.82 $223.55 $184.8222212 $184.82 $223.55 $184.8222401 $184.82 $223.55 $184.8222501 $184.82 $223.55 $184.8223101 $119.87 $119.87 $143.84 $119.8723102 $153.28 $153.28 $183.94 $153.28

Restoration, Amalgam/Composite; Prefabricated, Full CoveragePrimary incisor teeth are eligible only for clients under age 5. Restorations are subject to the distinct surface edit and 1 in any 12 months for same provider or different provider in the same office.

2.0 RESTORATIONCaries, Trauma and Pain ControlMaximum two (2) teeth in a lifetime, as an emergency.Caries, Trauma and Pain Control should not be considered for coverage in conjunction with any of the following procedures: restorations, open and drain, pulpectomy, pulpotomy, root canal if requested with the same date of service (DOS) and for the same tooth.





23103 $196.90 $196.90 $236.28 $196.9023104 $260.07 $260.07 $282.00 $260.0723105 $269.15 $269.15 $314.00 $269.1523111 $130.74 $130.74 $156.89 $130.7423112 $163.41 $163.41 $196.09 $163.4123113 $209.37 $209.37 $251.24 $209.3723114 $271.69 $271.69 $306.00 $271.6923115 $277.93 $277.93 $333.52 $277.9323211 $119.87 $119.87 $143.84 $119.8723212 $180.35 $180.35 $209.00 $180.3523213 $196.90 $196.90 $236.28 $196.9023214 $269.15 $269.15 $282.00 $269.1523215 $269.15 $269.15 $314.00 $269.1523221 $136.58 $136.58 $163.90 $136.5823222 $196.90 $196.90 $209.00 $196.9023223 $213.46 $213.46 $251.00 $213.4623224 $306.66 $306.66 $324.00 $306.6623225 $306.66 $306.66 $345.00 $306.6623311 $130.74 $130.74 $156.89 $130.7423312 $191.92 $191.92 $230.30 $191.9223313 $209.37 $209.37 $251.24 $209.3723314 $295.28 $295.28 $314.00 $295.2823315 $295.28 $295.28 $354.34 $295.2823321 $147.07 $147.07 $168.00 $147.0723322 $209.37 $209.37 $231.00 $209.3723323 $226.80 $226.80 $262.00 $226.8023324 $313.07 $313.07 $318.00 $313.0723325 $313.18 $313.18 $375.82 $313.1823401 $119.87 $143.84 $119.8723402 $153.28 $183.94 $153.2823403 $180.37 $216.44 $180.3723404 $184.82 $223.55 $184.8223405 $184.82 $223.55 $184.8223411 $132.11 $158.53 $132.1123412 $164.67 $197.60 $164.6723413 $184.82 $221.78 $184.8223414 $184.82 $223.55 $184.8223415 $184.82 $223.55 $184.8223501 $119.87 $143.8423502 $180.37 $209.0023503 $184.82 $221.7823504 $184.82 $223.5523505 $184.82 $223.5523511 $136.58 $163.9023512 $184.82 $221.7823513 $184.82 $221.7823514 $184.82 $223.5523515 $184.82 $223.55

25781 $71.44 $84.00 $86.47 $86.4725782 $142.87 $168.00 $172.93 $172.93

27721 $256.25 $312.5027722 L $75.94 $91.91

Post Removal1 in a lifetime, per permanent tooth

Repair to Crowns1 in any 36 months, per tooth





29101 $63.68 $76.42 $76.42

32221 $113.33 $140.89 $140.8932222 $181.76 $218.45 $218.1132232 $58.57 $75.38 $75.3832311 $113.33 $222.70 $164.2732312 $121.18 $230.35 $180.6932313 $181.76 $328.10 $225.2132314 $212.06 $430.10 $262.7532321 $113.33 $146.47 $146.4732322 $113.33 $150.74 $150.74

33111 $453.24 $602.65 $589.0533121 $566.55 $806.65 $788.8033131 $787.61 $958.80 $947.7533141 $908.79 $1,116.90 $1,103.30

39201 $54.52 $76.54 $76.5439202 $54.52 $76.54 $76.54

43421 $56.04 $67.2543422 $112.08 $134.5043423 $168.13 $201.7643424 $224.17 $269.0043427 $28.00 $33.60

42831 $84.02 $100.82 $100.82

51101 L $762.83 $923.2651102 L $970.84 $1,175.0351103 L $1,248.25 $1,497.90

54201 $63.97 $77.43

Recementation of Crowns1 in any 36 months, per tooth

The NIHB Endodontic Policy must be met. Please refer to the Provider Website: http://www.provider.express-scripts.ca/ for information on the NIHB dental policies.

Root PlaningAge 0 to 11: 1 unit in any 12 months in combination with scaling;Age 12 to 16: 2 units in any 12 months in combination with scaling;Age 17+: 4 units in any 12 months in combination with scaling;Predetermination is required for additional units.

Pulpotomy/PulpectomyNot covered for primary incisor teeth.

3.0 ENDODONTICS

4.0 PERIODONTICS

Open and Drain

Root Canal Therapy3 in any 36 months for all teeth. Once the frequency has been reached, subsequent RCT procedures require predetermination. Predetermination is required for 8's at all times.

Miscellaneous

Denture Adjustments

5.0 PROSTHODONTICS - REMOVABLEThe NIHB Removable Prosthodontic Policy must be met. Please refer to the Provider Website: http://www.provider.express-scripts.ca/ for information on the NIHB dental policies.The fee for complete and partial dentures includes a three (3) month period of post-insertion care. The fee for immediate dentures includes the tissue conditioner, but not the processed reline/rebase.Denture adjustments done on the same date of service and in conjunction with the delivery of new dentures, denture repairs, relines, rebases and/or tissue conditioning, are included in the fees billed and paid for these services.The overall cost of replacement for a denture may be adjusted in situations where claims for reline/rebase were paid within three months prior to the request.Complete Dentures - Standard1 per arch in any 96 months





55101 L $63.97 $77.4355102 L $63.97 $77.4355201 L $95.92 $116.1055202 L $95.92 $116.1055203 L $127.93 $153.5255301 L $63.97 $77.4355302 L $63.97 $77.4355401 L $191.87 $232.2255402 L $191.87 $232.2255403 L $255.81 $306.97

56211 $255.81 $309.6256212 $255.81 $309.6256213 $319.78 $383.7456221 $250.10 $300.1256222 $250.10 $308.5556223 $319.78 $383.7456231 L $255.81 $309.6256232 L $319.78 $387.0456233 L $399.71 $479.6556241 L $255.81 $306.9756242 L $255.81 $309.6256243 L $399.71 $479.6556311 L $255.81 $309.6256312 L $255.81 $309.6256313 L $415.70 $498.8456321 L $255.81 $309.6256322 L $255.81 $309.6256323 L $415.70 $498.84

56511 $127.93 $154.8456512 $127.93 $154.8456513 $183.67 $241.7756521 $127.93 $154.8456522 $127.93 $154.8456523 $196.37 $235.6456531 $127.93 $154.8456532 $127.93 $154.8456533 $183.67 $220.40

71101 $129.82 $155.78 $155.78 $129.8271109 $68.78 $82.54 $82.54 $68.7871201 $201.26 $212.00 $241.51 $201.2671209 $201.26 $210.00 $241.51 $201.2671211 $181.5571219 $136.0572311 $93.24 $112.85 $101.8772319 $88.87 $106.64 $96.5774111 $307.85 $369.42 $369.42 $369.42 $369.4274112 $328.35 $394.02 $394.02 $394.02 $394.0274121 $260.95 $313.14 $316.35 $316.35 $316.3574122 $362.42 $434.90 $434.90 $434.90 $434.9074211 $202.94 $243.53 $431.38 $431.38 $431.38

7.0 ORAL AND MAXILLOFACIAL SURGERY

Repairs and Additions1 per prosthesis in any 12 months

Reline or Rebase1 per prosthesis in any 24 months

Tissue Conditioning1 per prosthesis in any 24 months





74212 $301.23 $361.48 $439.34 $439.34 $439.3474221 $278.13 $333.76 $439.34 $439.34 $439.3474222 $418.82 $502.58 $502.58 $502.58 $502.5874611 $247.76 $297.31 $297.31 $297.31 $297.3174612 $273.71 $328.45 $328.45 $328.45 $328.4574621 $319.03 $382.84 $382.84 $565.91 $565.91 $565.9174631 $296.23 $355.48 $355.48 $355.48 $355.48 $355.4874632 $325.85 $391.02 $391.02 $391.02 $391.02 $391.0275111 $93.24 $112.85 $111.89 $124.80 $112.85 $235.6575112 $93.24 $112.85 $112.85 $213.0075113 $210.80 $252.96 $283.20 $283.2075121 $205.21 $248.37 $288.26 $288.2675122 $205.21 $248.37 $304.00 $308.8775123 $228.44 $274.13 $350.46 $350.4675211 $134.30 $161.16 $341.7075212 $410.74 $492.89 $492.8975221 $376.89 $452.27 $452.2775301 $314.00 $376.80 $424.3075303 $163.70 $196.44 $562.0076941 $150.11 $180.1376949 $150.11 $180.1376951 $83.88 $100.6676952 $167.72 $201.2676961 $102.6276962 $150.1179601 $41.93 $50.32 $50.32 $57.60 $66.00 $84.1579602 $41.93 $50.32 $50.32 $57.60 $67.00 $87.3579605 $51.33 $117.47 $117.4779606 $60.10 $159.34 $159.3479701 $463.7279702 $463.72

P1000 $111.81 $111.81 $111.81P1100 $447.25 $447.25 $447.25

92411 $58.37 $65.00 $73.00 $58.3792412 $82.11 $86.00 $102.00 $82.1192413 $107.18 $106.00 $131.00 $107.1892414 $132.24 $126.00 $161.00 $132.2492415 $157.29 $147.00 $190.83 $157.2992416 $185.53 $167.00 $222.64 $185.5392417 $185.53 $167.00 $222.64 $185.5392418 $185.53 $167.00 $222.64 $185.5392421 $58.37 $65.00 $73.00 $58.3792422 $58.37 $65.00 $73.00 $58.3792423 $58.37 $65.00 $73.00 $58.3792424 $58.37 $65.00 $73.00 $58.3792425 $58.37 $65.00 $73.00 $58.3792426 $58.37 $65.00 $73.00 $58.3792427 $58.37 $65.00 $73.00 $58.3792428 $58.37 $65.00 $73.00 $58.37

9.0 ADJUNCTIVE GENERAL SERVICESNIHB Sedation and General Anaesthesia Policy must be met. Please refer to the Provider Website:http://www.provider.express-scripts.ca/ for information on the NIHB dental policies. Nitrous oxide and oral sedation (stand-alone procedures and in combination)4 in any 12 month period

8.0 ORTHODONTICSThe NIHB Orthodontic Policy must be met. Please refer to the Provider Website: http://www.provider.express-scripts.ca/ for information on the NIHB dental policies.





92431 $67.09 $73.00 $90.05 $67.0992432 $104.66 $104.00 $125.59 $104.6692433 $142.26 $134.00 $170.71 $142.2692434 $181.02 $165.00 $217.22 $181.0292435 $218.00 $196.00 $261.60 $218.0092436 $252.00 $227.00 $302.40 $252.0092437 $252.00 $227.00 $302.40 $252.0092438 $252.00 $227.00 $302.40 $252.00


General Practitioners and SpecialistsSCHEDULE B

SCHEDULE B (GP/SP) Ontario NIHB Regional Dental Benefit Grid (Effective Date: April 1, 2020)Version 1.0 Page 1 of 6


01011 $44.66 $53.59

01401 $148.43 $157.0201501 $215.9101701 $215.9101801 $208.84

04101 L $55.12 $66.14 $66.14 $66.14 $56.00 $66.1404401 L $59.80 $71.76 $71.76 $71.76 $68.00 $71.76

04911 $36.11 $36.0004913 $59.00 $62.18

16201 $35.00

16511 $39.70 $39.7016517 $39.70 $39.70

22301 $171.64 $207.97 $171.6422302 $171.64 $207.97 $171.6422311 $171.64 $207.97 $171.6422312 $171.64 $207.97 $171.64

21301 $266.08 $319.3021302 $266.08 $319.3023601 $275.32 $330.3823602 $281.88 $346.4325731 $143.50 $138.00 $174.0425732 $215.25 $207.00 $261.0525733 $287.00 $276.00 $348.0425751 $273.68 $328.4225752 $273.68 $328.42

0.2 LABORATORY TESTSWhen submitting requests of laboratory tests/analysis, a copy of the laboratory report is required.

All Procedures in Schedule B have a Predetermination Requirement

0.0 DIAGNOSTIC0.1 EXAMINATIONSMaximum eligibility of examinations: ages 17+: up to 3 in any 12 months; under 17: up to 4 in any 12 months. Frequency limitations take into account overall interaction between various examination services rendered by same provider, different providers within the same office or different office, and their eligibility period.Specialty complete and Specialty limited examinations (performed by specialists only) will not count against the eligible maximum examinations allowable.First Dental Visit ExaminationUp to the age of three (3) inclusive

Specialist Examination and Diagnosis - Complete1 in any 60 months per specialty (with GP referral and justification for the referral).When a specialty complete examination is adjudicated, it eliminates specialty limited examination within the same specialty in that twelve (12) month period.

0.3 DIAGNOSTIC CASTS, UNMOUNTED

1.0 PREVENTIONInterproximal Disking of Teeth1 unit in any 12 months

Occlusal Adjustment/EquilibrationCost of one unit will be limited to the cost of half unit.

2.0 RESTORATION

Cores and Posts4 in any 120 months, on permanent tooth only.Eligible only for clients age 18 and older.Cores are eligible only if existing restoration is greater than twelve (12) months old.Cores may be considered for coverage only in conjunction with an approved predetermination crown request.A prefabricated post/pin is eligible only when inadequate coronal tooth structure is remaining to retain a restoration.Prefabricated posts in combination with core, including pin(s) where applicable, may be considered for coverage only in conjunction with an approved predetermination crown request.

Prefabricated, Full Coverage






25753 $273.68 $328.4225754 $273.68 $342.8325755 $273.68 $342.8325756 $273.68 $342.8325761 $273.68 $328.4225762 $273.68 $328.4225763 $273.68 $328.4225764 $365.85 $442.8025765 $365.85 $442.8025766 $365.85 $442.80

27201 L $714.40 $911.4227211 L $714.40 $911.4227301 L $651.02 $787.94

33111 $453.24 $602.65 $589.0533121 $566.55 $806.65 $788.8033131 $787.61 $958.80 $947.7533141 $908.79 $1,116.90 $1,103.30

33115 $615.00 $738.00 $738.0033125 $735.95 $883.14 $889.9533135 $1,013.73 $1,228.34 $1,228.3433145 $1,138.78 $1,379.86 $1,379.8633601 $364.75 $441.97 $441.9733602 $427.78 $518.35 $518.3533603 $557.88 $675.98 $675.9833604 $642.11 $778.05 $778.0533605 $79.14 $94.97 $94.9733611 $107.16 $129.85 $129.8533612 $134.17 $161.00 $161.0033613 $161.18 $161.00 $193.4233614 $161.18 $195.30 $195.3033621 $288.00 $444.55 $444.5533622 $397.00 $613.70 $613.7033623 $463.00 $714.85 $714.8533624 $556.00 $859.36 $859.3634111 $335.18 $406.13 $406.1334112 $388.58 $470.84 $470.8434121 $284.90 $345.21 $345.2134122 $396.42 $480.34 $480.3434123 $453.05 $548.96 $548.9634131 $284.90 $345.21 $345.2134132 $396.42 $480.34 $480.3434133 $453.05 $548.96 $548.9634134 $499.23 $604.92 $604.9234141 $335.18 $406.13 $406.13

Crowns4 in any 120 months per clientThe NIHB Crown Policy must be met. Please refer to the Provider Website: http://www.provider.express-scripts.ca/ for information on the NIHB dental policies.

3.0 ENDODONTICSThe NIHB Endodontic Policy must be met. Please refer to the Provider Website: http://www.provider.express-scripts.ca/ for information on the NIHB dental policies.Root Canal TherapyEligible three (3) in any 36 months for all teeth. Once the frequency has been reached, subsequent RCT procedures require predetermination. Predetermination is required for 8's at all times.

Re-treatment of Root Canal Therapy, Apicoectomy and RetrofillingOne (1) root canal re-treatment, one (1) apicoectomy and one (1) retrofilling per tooth, per lifetime






34142 $396.42 $480.34 $480.3434151 $340.66 $412.78 $412.7834152 $533.00 $645.84 $645.8434153 $509.68 $617.58 $617.5834161 $340.66 $412.78 $412.7834162 $493.25 $597.68 $597.6834163 $509.68 $617.58 $617.5834164 $566.31 $686.21 $686.2134211 $64.52 $78.18 $78.1834212 $73.19 $88.68 $88.6834221 $57.50 $69.68 $69.6834222 $73.19 $88.68 $88.6834223 $85.38 $103.46 $103.4634224 $115.01 $139.35 $139.3534231 $73.19 $88.68 $88.6834232 $85.38 $103.46 $103.4634233 $115.01 $139.35 $139.3534234 $142.01 $172.08 $172.0834241 $67.65 $81.97 $81.9734242 $73.19 $88.68 $88.6834251 $57.50 $69.68 $69.6834252 $73.19 $88.68 $88.6834253 $85.38 $103.46 $103.4634254 $115.01 $139.35 $139.3534261 $73.19 $88.68 $88.6834262 $85.38 $103.46 $103.4634263 $115.01 $139.35 $139.3534264 $142.01 $172.08 $172.08

41211 $46.50 $55.80 $55.80 $55.8041221 $46.50 $55.80 $55.80 $55.8041231 $46.50 $55.80 $55.80 $55.80

41301 $55.82 $55.82

43211 $84.02 $100.8243221 $170.01 $201.0043231 $42.04 $78.2043241 $84.02 $100.8243281 $81.42 $97.70

49101 $84.02 $101.1549102 $84.02 $101.15

Desensitization

4.0 PERIODONTICSManagement of Oral DiseaseEligible once (1) in any twelve (12) month period.

Periodontal Splint or Ligation, Provisional, Extra Coronal

Periodontal Re-Evaluation/EvaluationLimited to those clients with an identified periodontal problem.Not to be used in conjunction with procedure code 01502.






51301 L $901.49 $1,091.0951302 L $1,109.54 $1,342.8951303 L $1,386.93 $1,664.3251711 L $971.58 $1,175.9351712 L $1,195.80 $1,447.3051713 L $1,533.76 $1,840.5152101 L $319.78 $387.0452102 L $319.78 $387.0452103 L $415.70 $498.8452301 L $554.77 $671.4652302 L $554.77 $671.4652303 L $762.83 $915.4053101 L $970.84 $1,175.0353102 L $970.84 $1,175.0353103 L $1,386.93 $1,664.3253201 L $901.49 $1,091.0953202 L $901.49 $1,091.0953203 L $1,317.58 $1,581.1053301 L $1,317.58 $1,594.6953302 L $1,317.58 $1,594.69

72111 $200.3972119 $200.3972211 $300.5872219 $300.5872221 $399.9072229 $399.9072231 $437.1772239 $437.1772321 $186.48 $205.5972329 $176.86 $193.1372331 $205.2172339 $193.8872511 $93.24 $112.85 $112.8572519 $93.24 $112.85 $112.8572521 $307.85 $369.42 $369.4272529 $296.23 $355.48 $355.4872531 $307.85 $382.8772539 $296.23 $355.4872541 $186.09 $444.9072551 $290.08 $497.0473121 $205.22 $246.2673411 $205.21 $246.25

5.0 PROSTHODONTICS - REMOVABLEThe NIHB Removable Prosthodontic Policy must be met. Please refer to the Provider Website: http://www.provider.express-scripts.ca/ for information on the NIHB dental policies.The fee for complete and partial dentures includes a three (3) month period of post-insertion care. The fee for immediate dentures includes the tissue conditioner, but not the processed reline/rebase.Denture adjustments done on the same date of service and in conjunction with the delivery of new dentures, denture repairs, relines, rebases and/or tissue conditioning, are included in the fees billed and paid for these services.The overall cost of replacement for a denture may be adjusted in situations where claims for reline/rebase were paid within three months prior to the request.Complete/Partial Cast/Immediate Dentures1 per arch in any 96 monthsPartial Acrylic Dentures1 per arch in any 60 months

7.0 ORAL AND MAXILLOFACIAL SURGERY






75302 $402.00 $482.4075401 $137.39 $164.8775403 $130.50 $156.60 $156.60 $156.6075411 $347.9575412 $434.9476201 $475.00 $859.9676301 $682.41 $818.8979603 $93.24 $111.89 $111.89 $111.89 $112.85 $111.8979604 $93.24 $111.89 $111.89 $111.89 $112.85 $111.89

80602 $76.44 $76.4480661 $76.44 $76.4480669 $76.44 $76.4480671 $76.44 $76.4480679 $76.44 $76.4481111 L $229.36 $229.3681112 L $229.36 $229.3681113 L $229.36 $229.3681114 L $224.21 $224.2181121 L $229.36 $229.3681122 L $229.36 $229.3681131 L $299.30 $299.3081132 L $299.30 $299.3081135 L $449.98 $449.9881211 L $382.28 $382.2881212 L $382.28 $382.2881221 L $229.36 $229.3681222 L $229.36 $229.3681231 L $229.36 $229.3681232 L $229.36 $229.3681241 L $305.83 $305.8381242 L $305.83 $305.8381243 L $305.83 $305.8381251 L $517.63 $517.6381252 L $517.63 $517.6381253 L $458.78 $458.7881254 L $382.26P0500 $60.27 $60.27 $60.27P1200 $2,341.27 $2,341.27 $2,341.27P1300 $1,951.07 $1,951.07 $1,951.07P1400 $1,560.83 $1,560.83 $1,560.83

92212 $178.28 $223.55 $220.6192213 $240.94 $289.13 $289.1392214 $303.59 $364.31 $364.3192215 $365.93 $439.12 $439.1292216 $424.00 $508.80 $508.8092217 $424.00 $508.80 $508.8092218 $424.00 $508.80 $508.8092222 $97.20 $78.00 $116.00

The NIHB Orthodontic Policy must be met. Please refer to the Provider Website: http://www.provider.express-scripts.ca/ for information on the NIHB dental policies. Note: Approved fees for P1500 are based on the treatment plan provided. Please see Schedule A - Section 8.0 Orthodontics for procedures P1000 and P1100.

9.0 ADJUNCTIVE GENERAL SERVICESNIHB Sedation and General Anaesthesia Policy must be met. Please refer to the Provider Website:http://www.provider.express-scripts.ca/ for information on the NIHB dental policies.

8.0 ORTHODONTICS






92223 $145.86 $103.00 $174.0092224 $194.47 $128.00 $231.0092225 $243.07 $153.00 $289.0092226 $291.69 $179.00 $347.0092227 $291.69 $179.00 $347.0092228 $291.69 $179.00 $347.0092301 $64.75 $118.35 $118.3592302 $178.28 $223.55 $215.0592303 $240.94 $289.13 $289.1392304 $303.59 $364.31 $364.3192305 $365.93 $439.12 $439.1292306 $424.00 $508.80 $508.8092307 $424.00 $508.80 $508.8092308 $424.00 $508.80 $508.8092321 $41.43 $49.72 $49.7292322 $82.84 $78.00 $99.4192323 $123.33 $103.00 $148.0092324 $164.73 $128.00 $197.6892325 $206.16 $153.00 $247.3992326 $246.63 $179.00 $295.9692327 $246.63 $179.00 $295.9692328 $246.63 $179.00 $295.9692441 $91.09 $78.00 $109.31 $91.0992442 $153.72 $124.00 $184.46 $153.7292443 $212.00 $170.00 $254.40 $212.0092444 $269.00 $215.00 $322.80 $269.0092445 $326.00 $261.00 $391.20 $326.0092446 $383.00 $306.00 $459.60 $383.0092447 $383.00 $306.00 $459.60 $383.0092448 $383.00 $306.00 $459.60 $383.0092451 $126.52 $151.82 $151.8292452 $175.10 $210.12 $210.1292453 $234.96 $281.95 $281.9592454 $292.56 $351.07 $351.0792455 $351.31 $421.57 $421.5792456 $409.70 $491.64 $491.6492457 $409.70 $491.64 $491.6492458 $409.70 $491.64 $491.6494302 $57.5599111 I.C. I.C.99222 I.C. I.C. I.C. I.C. I.C. I.C.99333 I.C. I.C.

Date post:	09-Aug-2020
Category:	Documents
Upload:	others
View:	4 times
Download:	1 times

Communication to all NIHB General Practitio ners ......and criteria of dental services eligible...

Documents