When does administration of dental benefits for FNHA clients transition to Pacific Blue Cross?
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.
How do I process claims prior to the transition date?
Please continue to submit claims to NIHB/ESC as usual leading up to September 16.
What actions do I need to take to prepare for the transition on 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.
- Visit pac.bluecross.ca/provider
- Select New Providers
- Select Dental
- Under Account Management, select Register for a NEW account with Pacific Blue Cross.
- 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.
What is PROVIDERnet?
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.
What are the benefits of using PROVIDERnet?
- Quick, easy, and secure
- Claim payments directly deposit into your bank account
- Online claim statements
- Access to updated user guides and supplements
Is there a charge for using PROVIDERnet?
Access to PROVIDERnet is free for all Providers.
Who is eligible to register for PROVIDERnet?
To register for PROVIDERnet, you must be a:
- 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.
How long does it take to register for PROVIDERnet?
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.
What is the difference between a Primary Account Administrator and a Standard Account Administrator in PROVIDERnet?
- 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.
How do I add a Standard Account Administrator?
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.
What is my Provider ID?
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.
I am having trouble signing into PROVIDERnet, who do I contact for help?
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.
How do I upload my direct deposit information in PROVIDERnet?
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.
Claims Processing Information – For First Nations Health Authority (FNHA) client claims after September 16, 2019
Will the process for submitting dental claims, Pre-Determinations, and treatment plans for FNHA clients change?
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.
How will I know if a BC First Nations client is covered under the new plan?
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).
My office submitted a Pre-Determination or treatment plan to NIHB for a service scheduled after September 16. Will we need to re-submit or will it be transferred to the new plan?
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.
We submitted a Pre-Determination on behalf of an FNHA client prior to September 16, and it was denied. Should we re-submit after September 16?
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.
Will Pre-Determinations issued before September 16 be paid at the NIHB rate or the Pacific Blue Cross Fee Schedule/Supplement rate, if the treatment is performed after September 16?
Claims processed as of September 16 will be reimbursed at the rate listed in the Pacific Blue Cross dental fee schedule/supplement.
Benefits Information - For FNHA client claims after September 16, 2019
How do we find out which services are eligible under the new plan?
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.
What will be included in FNHA's Dental Accident Coverage?
FNHA clients will have Pacific Blue Cross' Standard Dental Accident Coverage as outlined in the Dental Fee Schedule.
Will dental reimbursement rates change with the transition to PBC?
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.
Will there be improved coverage for dentures?
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.
If I have questions about the new FNHA benefits plan for dental, who should I contact for information?
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.
What if my client does not know their ID number?
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.
How do I read the First Nations Health Authority Fee Supplement in conjunction with the Pacific Blue Cross Fee Schedule?
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.
Is the First Nations Health Authority different than Non-Insured Health Benefits?
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.
Will the First Nations Health Authority transition from Non-Insured Health Benefits to Pacific Blue Cross impact Dental Providers operating outside British Columbia (e.g. Alberta, Manitoba)?
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.
For the First Nations Health Authority Plan, how long do I have to submit claims electronically for adjudication?
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.
Do we need an original signature on claim forms, or can we write ‘signature on file’?
For paper submissions, we require the original signature on the claim form. For EDI submissions, please ensure you have a signature on file.
Will Electronic Claims be rejected if the client’s signature is not on file?
Yes, please follow Pacific Blue Cross Standard Practice.
Do dental providers need to use the Non-Insured Health Benefit’s Dent-29 form for Pre-Determinations?
Please use the Pacific Blue Cross or the appropriate Canadian (Dental, Hygiene or Denturist) Association standard claim forms when submitting pre-determinations.
Where does Jordan’s Principle come into play with the new Dental Plan for First Nations Health Authority?
There are no changes to Jordan’s Principle as a result of the transition.
Can independent Dental Hygiene Providers use the same CDHA dental claim form for policy 40000?
How do Dental Providers retract claims?
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.
How do we know if our client has First Nations Health Authority or Non-Insured Health Benefits coverage?
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.
I have approval for treatment under the former Non-Insured Health Benefits coverage. Will I need to amend anything to have the work done for Pacific Blue Cross? What if the treatment remains the same but the code requires modification?
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.
Can pre-determinations be sent electronically with an immediate response?
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.
Who signs the claim form if the patient is a child?
Please follow Pacific Blue Cross’ standards of practice which allows a child’s guardian to sign on their behalf.
Just to clarify, a First Nations person resident in British Columbia would fall under the First Nations Health Authority coverage and not Non-Insured Health Benefits?
Yes, if they are eligible under the First Nations Health Authority client criteria as outlined in the Pacific Blue Cross Dental Reference Guide.
If we treat an out-of-province status patient, do we submit the claim to Non-Insured Health Benefits?
Will payments be separate for First Nations Health Authority clients and Pacific Blue Cross clients?
No. Pacific Blue Cross will provide combined statements for all.
Root Canals & Crowns
Are wisdom teeth (8s) also eligible for Endodontic work?
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.
How do you receive authorization for crowns with Pacific Blue Cross for First Nations Health Authority clients?
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.
Are there still only two root canals available per calendar year for First Nations Health Authority clients?
Standard Pacific Blue Cross limits and rules apply; root canals are limited to one per tooth per lifetime.
Are the First Nations Health Authority dental codes different than those listed in the provincial guides?
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.
Is there still a 3-month wait period before a crown can be approved on a recently root-canaled tooth?
Will the pulpectomy be deducted when the root canal is completed?
Yes; please submit claim as per the requirements outlined in the Pacific Blue Cross Dental Fee Schedule.
What are the limits for crown coverage?
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.
Does the First Nations Health Authority plan still require a 6-month time lapse between root canals and crowns?
Is ‘Porcelain Fused to Gold’ the only tooth-colour option for crowns?
No. Porcelain fused to metal base (PFM), ceramic/porcelain and full gold crowns are eligible for coverage.
Coordination of Benefits
Which coverage is the primary payor when there is both Ministry and First Nations Health Authority coordination of benefits.
Ministry Coverage will be primary to First Nations Health Authority Coverage.
Will Pacific Blue Cross Coordinate Ministry Coverage with First Nations Health Authority Plans internally?
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.
If we sent a manual claim to the Ministry emergency coverage, can we also attach the Pacific Blue Cross form for the First Nations Health Authority coverage for faster coordination of benefits?
Can we send a fax to Pacific Blue Cross for final payment if we receive proof of primary coverage?
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.
What do I do if we are having an issue with a claim submitted before September 16th, 2019? Do I contact Pacific Blue Cross or Non-Insured Health Benefits?
On or after September 16th, 2019, regardless of the date service, contact Pacific Blue Cross if you have any questions concerning First Nations Health Authority claims.
What is covered for anesthesia for children?
Please refer to the First Nations Health Authority Fee Supplement Table 1 for full sedation criteria.
What are the rules for Parental conscious sedation when required for full mouth restorations under sedation for children under the age of 12?
Please refer “Table 1” in the First Nations Health Authority Fee Supplement which indicates claiming criteria.
Are there any limits to Nitrous (Minimal Sedation) including age restrictions?
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.
Do we need a pre-determination for Oral Sedation If we are a pediatric surgery practice?
Yes. Please refer to the First Nations Health Authority Fee Supplement. Only Oral Surgeons are exempt from the pre-determination criteria.
Does the First Nations Health Authority plan cover Nitrous Oxide Sedation?
Yes - under Minimal Sedation.
Do we need to submit start and end time for Nitrous Oxide Sedation for coverage consideration?
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.
What is the process for appeals, specifically for orthodontics?
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.
Do you still require orthodontic style models for pre-determinations?
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.
Can orthodontic work only be completed by orthodontic specialists, or can general dental practitioners provide these services for First Nations Health Authority clients?
First Nations Health Authority clients can receive orthodontic treatments from all Pacific Blue Cross eligible Providers, including both general practitioners and orthodontic specialists.
I work in an orthodontist office. We have claim forms signed for all p1200, p1300 and p1400 on Dent-29 forms. Do we need to re-do the claim forms on Pacific Blue Cross standard claim forms?
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.
Specific Claiming Criteria
What are the criteria for removable Partial Dentures? Are there limits to the number of teeth that need to be missing?
No, please follow Pacific Blue Cross Standards.
What is the coverage for night guards?
Limited to two appliances per person in a 60-month period.
What is the coverage for X-rays?
$95/2 per client, per calendar year.
Do oral surgery practices require pre-determinations for sedation?
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.
Are clients eligible to have coverage for fillings completed by different Providers?
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.
What happens when our clients at high risk for recurring carries cannot receive treatment resulting from Pacific Blue Cross’ standards for restoration limits?
In situations where there are exceptional needs, please send documentation supporting the request for additional coverage to Pacific Blue Cross for consideration.
Will the new scaling limit backdate to the start date of 2019?
Yes, this is a calendar-year limit. Claims history will be loaded for all First Nations Health Authority clients for accumulation purposes.
Does the First Nations Health Authority plan cover Silver Diamine Fluoride?
Do we need to set up Fee Schedule Three for First Nations Health Authority in our Dental Software?
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.
In the ‘Prosthodontic Section’ of the First Nations Health Authority Fee Supplement, the fee codes are in the 50000’s. Where are the Denturists’ fee codes?
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.
Will partial dentures still require photos of models on file as part of the ‘Partial Denture Trial Project’?
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.
Will the First Nations Health Authority coverage reimburse the client directly if the dental practice is non-assignment?
Yes, we will reimburse the client. We appreciate all dental offices supporting clients to reduce out-of-pocket expenses whenever possible.
We are a not-for-profit under a single unique number for Dentists, can we process claims on behalf of First Nations Health Authority clients?