The transition of dental benefits takes place on September 16, 2019. As of September 16, the FNHA asks all Dental Providers to please submit claims to Pacific Blue Cross using the Policy number 40000. Member ID numbers for FNHA clients match their Status Numbers. Clients may show you a Certificate of Indian Status Card or Pacific Blue Cross Member ID card to verify coverage.

A new fee supplement and updated reference guide will be posted on pac.bluecross.ca/provider prior to September.

Please continue to submit claims to NIHB/ESC as usual leading up to September 16.

If you have not registered as a Provider with Pacific Blue Cross, please do so prior to September 16 in order to process claims on behalf of FNHA clients. After registering as a Provider, you will be able to register online for Pacific Blue Cross’s convenient online claims management system, PROVIDERnet. Visit pac.bluecross.ca/provider to register.

Registering as a Provider is quick and easy.

Make sure to have your unique 9-digit number (UIN) assigned by the CDA/DAC/CDHA, your 4-digit office number assigned by the CDA/DAC/CDHA, as well as your office address on hand before you begin.

1. Visit pac.bluecross.ca/provider
2. Select New Providers
3. Select Dental
4. Under Account Management, select Register for a NEW account with Pacific Blue Cross.
5. Fill out the online Provider application.

You will receive an email confirmation upon completing the online form that your application has been received (processing may take up to 5 business days) and you’ll be ready to activate your account.

PROVIDERnet is an efficient online claim management tool from Pacific Blue Cross that allows Dental Providers the ability to upload their direct deposit information, check eligibility, view pre-authorizations, access claim statements and download helpful guides and resources.

• Quick, easy, and secure
• Claim payments directly deposit into your bank account
• Online claim statements
• Access to updated user guides and supplements

Access to PROVIDERnet is free for all Providers.

To register for PROVIDERnet, you must be a:

• Dentist
• Denturist
• Independent Hygienist

To be eligible as a Dental Provider you will need to know your 9-digit UIN number assigned by CDA/DAC/CDHA and your 4-digit office number assigned by CDA/DAC/CDHA.

The initial online registration for PROVIDERnet takes less than five minutes. After your initial online registration, processing of your account may take up to five business days. Please note: It is not necessary to submit more than one application. Once processed and approved, you will receive an email confirmation with your login information.

• A Primary Account Administrator is the dental practitioner who has access to add/edit banking information, as well as view pre-authorizations and claim statements. The Primary Administrator can also set up another Primary Administrator if they choose to grant someone else that main role (i.e. office manager) or other Standard Administrators (front desk staff).
• A Standard Account Administrator is a secondary account to the Primary Administrator account. They have access to eligibility, claim statements and pre-authorizations, but do not have access to view or change banking information.

The Primary Administrator can set up a Standard Administrator when logged in to PROVIDERnet:

• Sign in to your account at pac.bluecross.ca/provider
• Select Account > Administer User Accounts > Create New User Account
• Enter First Name, Last Name and the email address of the person you want assigned to that role.
• Select Role: Primary Administrator or Standard.

Your Provider ID is the 4-digit office number assigned to you by the CDA/DAC/CDHA, or a 4-digit number Pacific Blue Cross has assigned to your office.

If you have not signed in for six months or longer, your PROVIDERnet account will be considered inactive. To reactivate your account, please contact Pacific Blue Cross directly at 604-419-2000, or toll-free at 1-877-722-2583, Monday to Friday 8am - 4:30pm.

If you cannot remember your PROVIDERnet account password, you can request a password reset. The temporary password will be sent to the email on file and will expire after 24 hours.

Once you've registered for PROVIDERnet and are logged in, you'll find the option for direct deposit. You will need your bank transit, institution and account number to complete your direct deposit request. Dental Providers can choose to add different bank account information for each location at which they are working.

Please note: To ensure privacy and security, Pacific Blue Cross staff cannot set up direct deposit information. This is a self-serve function only.

Yes. Dental Service Providers will check coverage for FNHA clients through the Pacific Blue Cross system as of September 16. Pre-Determinations and treatment plans will also be processed and adjudicated by Pacific Blue Cross, based on FNHA’s new plan design. Claims can be transmitted using your existing software.

Client eligibility is determined by FNHA. FNHA clients who received their benefits under the NIHB program will be automatically enrolled on the new plan under Pacific Blue Cross, effective September 16, under Pacific Blue Cross policy number 40000. Group Plan ID numbers will be matched to Status Card numbers. As of September 16, you will need to contact FNHA at 1-855-550-5454 (extension 2 for other inquiries, followed by extension 1 for the Eligibility Unit).

For the few services where a Pre-Determination is required, the Pre-Determination will be transferred to Pacific Blue Cross. If you experience any issues during this process, please contact Pacific Blue Cross, or attach a copy of the Pre-Determination with your claim.

Yes. Approvals for Pre-Determinations under the new FNHA Dental plan may be different. As Pacific Blue Cross is streamlining the approval process for efficiency, some services will no longer require a Pre-Determination.

Claims processed as of September 16 will be reimbursed at the rate listed in the Pacific Blue Cross dental fee schedule/supplement.

Details of the new FNHA benefits plan with Pacific Blue Cross will be made available on the Pacific Blue Cross website. As of September 16, Dental Service Providers can sign in to PROVIDERnet at pac.bluecross.ca/provider to check FNHA client coverage online.

FNHA clients will have Pacific Blue Cross' Standard Dental Accident Coverage as outlined in the Dental Fee Schedule.

As of September 16, reimbursement rates for dental coverage for FNHA clients will align with the Pacific Blue Cross Fee Schedule. Plan details will be available for clients on the Pacific Blue Cross website through their Member Profile account (pac.bluecross.ca), or the Pacific Blue Cross Mobile App (visit pac.bluecross.ca/mobile for details), and for Providers on pac.bluecross.ca/provider.

Yes. There will be improved coverage in the new plan in terms of coverage and frequency for dentures and partial dentures. Details of the new plan design will be communicated prior to September on pac.bluecross.ca/provider, including a reference guide and fee supplement.

Leading up to September 16, please contact FNHA at 1-855-550-5454. Once the new plan is launched through Pacific Blue Cross on September 16, Providers may contact PBC, as they do for all other enquires, at 1-604-419-2000 or toll-free at 1 877 PAC-BLUE.

As of September 16, the client will need to contact the FNHA at 1-855-550-5454 to speak with the FNHA Eligibility Unit. Please note: For privacy reasons, Pacific Blue Cross cannot provide a client's ID number to a third party.

Please refer to the First Nations Health Authority Fee Supplement first when looking for a specific procedure or code. If this code is listed in the First Nations Health Authority Fee Supplement, the rules outlined supersede those listed in the Pacific Blue Cross Fee Schedule. If the First Nations Health Authority Fee Supplement references the Pacific Blue Cross Fee Schedule, all rules in the Pacific Blue Cross Fee Schedule remain. If the code requested is not referenced in either the First Nations Health Authority Fee Supplement or the Pacific Blue Cross Fee Schedule, it is not an eligible benefit.

Yes. Non-Insured Health Benefits coverage will continue for First Nations and Inuit people across Canada for those outside British Columbia. The First Nations Health Authority provides coverage for all First Nations people that are residents of British Columbia. Please refer to the Dental Reference Guide for more information about First Nations Health Authority client eligibility.

Regardless of where the Dental Provider is operating, the transition will impact any provider that is supporting a First Nations Health Authority client (according to the eligibility criteria outlined in the Pacific Blue Cross Dental Reference Guide). No change will be experienced if the Provider is servicing a First Nations client with Non-Insured Health Benefits Coverage.

Pacific Blue Cross accepts claims up to 12 months from the date of service; however, we expect all claims to be submitted directly after work is completed.

For paper submissions, we require the original signature on the claim form. For EDI submissions, please ensure you have a signature on file.

Yes, please follow Pacific Blue Cross Standard Practice.

Please use the Pacific Blue Cross or the appropriate Canadian (Dental, Hygiene or Denturist) Association standard claim forms when submitting pre-determinations.

There are no changes to Jordan’s Principle as a result of the transition.

Yes

Pacific Blue Cross standard claim reversal processes are in place for First Nations Health Authority clients. For claims submitted through EDI, you can reverse the claim electronically. For manual claims, send in the reversal request to Pacific Blue Cross with all supporting documentation. Please see the Pacific Blue Cross Dental Reference Guide for additional information on reversals or adjustments.

There are a variety of ways in which you can determine client eligibility. If you have PROVIDERnet, you can quickly determine if the client has First Nations Health Authority coverage. Search for the client by 1) indicating the policy number (40000) and 2) their Status Number (Identification Number) when querying for a generic fee code. If the client’s coverage is retrieved, they have First Nations Health Authority coverage. Alternatively, during Pacific Blue Cross hours of operation, you can call our call centre toll free at 1-877-722-2583 and one of our customer service agents will be able to determine coverage status.

Dental pre-determination will follow the client during the transition between Non-Insured Health Benefits and Pacific Blue Cross. If the Provider determines that a new procedure is required, that was not included in the pre-determination, the request must be re-submitted and amended in the same processes as currently handled with Pacific Blue Cross.

In some cases, pre-determinations can go through electronically and may provide approval in real time. If we require supporting documentation, the immediate response will indicate the need to submit the pre-determination on paper so that we can receive additional information (e.g. X-rays, photographs, or study models) required in the clinical description.

Please follow Pacific Blue Cross’ standards of practice which allows a child’s guardian to sign on their behalf.

Yes, if they are eligible under the First Nations Health Authority client criteria as outlined in the Pacific Blue Cross Dental Reference Guide.

Yes.

No. Pacific Blue Cross will provide combined statements for all.

8s for root canals will be considered on the same basis as teeth 1 through 7. This is the same as Pacific Blue Cross standard; please refer to the Pacific Blue Cross Fee Schedule and the First Nations Health Authority Fee Supplement for more information.

Crown authorization for First Nations Health Authority clients is the same as all Pacific Blue Cross patients. Some crowns are eligible for electronic pre-determinations, apart from the anteriors.

Standard Pacific Blue Cross limits and rules apply; root canals are limited to one per tooth per lifetime.

All the codes for the First Nations Health Authority plan are the same listed in the provincial guides, aside from a few Pacific Blue Cross specific orthodontic codes which exist in the Pacific Blue Cross Fee Schedule.

No.

Yes; please submit claim as per the requirements outlined in the Pacific Blue Cross Dental Fee Schedule.

The First Nations Health Authority plan follows Pacific Blue Cross standard (once per tooth, every 5-years and subject to the criteria outlined in the Pacific Blue Cross Fee Schedule). In addition to all Pacific Blue Cross standard consultant reviews on dental work, any First Nations Health Authority client receiving major services in excess of $4500.00 over a 5-year period will require subsequent claims to be submitted with supporting documentation for consultant review prior to consideration.

No

No. Porcelain fused to metal base (PFM), ceramic/porcelain and full gold crowns are eligible for coverage.

Ministry Coverage will be primary to First Nations Health Authority Coverage.

Yes. It should be noted that Ministry and First Nations Health Authority (FNHA) coverage in our system does not provide automated coordination of benefits. We can coordinate benefits between the plans, however it will not happen automatically. For electronic claims, please submit to the Ministry coverage first and then submit a second submission to the FNHA plan as an EDI COB claim. For paper claims, every submission must always indicate both coverages on the claim form to ensure manual coordination internally.

Yes.

Pacific Blue Cross will accept rush pre-determinations submitted by fax for FNHA clients. Incomplete forms will be rejected and must be resubmitted. Claims that cannot be sent electronically must be submitted by paper. If you require support with an adjustment or have a client that requires immediate attention, please call us at 604-419-2000 for additional support.

On or after September 16^th, 2019, regardless of the date service, contact Pacific Blue Cross if you have any questions concerning First Nations Health Authority claims.

Please refer to the First Nations Health Authority Fee Supplement Table 1 for full sedation criteria.

Please refer “Table 1” in the First Nations Health Authority Fee Supplement which indicates claiming criteria.

Yes. Minimal Sedation is limited to 4-units per visit, with 4 visits per year. Please refer “Table 1” in the First Nations Health Authority Fee Supplement which indicates claiming criteria.

Yes. Please refer to the First Nations Health Authority Fee Supplement. Only Oral Surgeons are exempt from the pre-determination criteria.

Yes - under Minimal Sedation.

No. Please submit the units of time of the sedation as per the requirements in Table 1 of the First Nations Health Authority Fee Supplement.

A Dental Provider or First Nation Health Authority client can escalate a claim or pre-determination review to the Pacific Blue Cross Benefit Review Committee. Please submit all documentation and reasons for request by mail to: PO Box 7000, Vancouver, BC V6B 4E1.

Yes, we require study models and/or photos of study models that demonstrate the criteria in the Handicapping Labio-Lingual Deviation guidelines are being met.

First Nations Health Authority clients can receive orthodontic treatments from all Pacific Blue Cross eligible Providers, including both general practitioners and orthodontic specialists.

No. If you already have the signatures on the Non-Insured Health Benefits documentation during the transitionary period, you can submit this paperwork to Pacific Blue Cross. We will honor the Non-Insured Health Benefits forms that have already been completed.

No, please follow Pacific Blue Cross Standards.

Limited to two appliances per person in a 60-month period.

$95/2 per client, per calendar year.

Oral surgeons performing sedation do not require pre-determinations. General practitioners performing sedation will require pre-determination. Please refer to the First Nations Health Authority Dental Fee Supplement for more information.

We will provide coverage for up to the 5-surface filling, in a two-year period. Coverage is not limited to certain Providers. The First Nations Health Authority plan also allows for coverage of fillings that have fallen out. Please refer to the First Nations Health Authority Fee supplement for additional information.

In situations where there are exceptional needs, please send documentation supporting the request for additional coverage to Pacific Blue Cross for consideration.

Yes, this is a calendar-year limit. Claims history will be loaded for all First Nations Health Authority clients for accumulation purposes.

No.

First Nations Health Authority clients will have schedule Three in the Pacific Blue Cross Fee Schedule. This should already be set-up in your Dental Software. Please ensure that you are transmitting electronic claims to Pacific Blue Cross, not Non-Insured Health Benefits.

Pacific Blue Cross follows the Uniform System of Codes and List of Services for Dentists and follow the Denture Association of Canada Listing for the Denturists. Please refer to the Denturists section of the First Nations Health Authority Fee Supplement for Denturist codes.

Partial denture coverage for First Nations Health Authority clients will follow Pacific Blue Cross’s standard practice. The ‘Partial Denture Trial Project’ is no longer applicable.

Yes, we will reimburse the client. We appreciate all dental offices supporting clients to reduce out-of-pocket expenses whenever possible.

Yes.