PRINCE EDWARD ISLAND NIHB Regional Dental Benefit Grid Oral and Maxillofacial Surgeons

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Emerald Lynch
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1 Effective Date May 1, 2016 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

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

3 SCHEDULE A Code Lab. O. Surg 0.0 DIAGNOSTIC 0.1 EXAMINATIONS Maximum 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 Diagnosis $ Specific/ Emergency Examinations 1 in any 12 months $ $34.96 Specialist Examination and Diagnosis - Limited 1 in any 12 months $ $ RADIOGRAPHS Intraoral, Complete Series 1 in any 60 months Not to be covered in conjunction with a panoramic radiograph for the time period (60 months) $ $ $ $ $ $ $91.53 Intraoral (1-10 films) 10 in any 12 months Panoramic $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $65.42 SCHEDULE A (OS) Prince Edward Island (Effective Date: May 1, 2016) Version 1.0 Page 1 of 4

eligibility period. Specialty complete and Specialty limited examinations (performed by specialists only) will not count against the eligible maximum examinations allowable.

4 SCHEDULE A Code Lab. O. Surg Cephalometric $ $71.98 Tomography $ $ $ $ $ $ LABORATORY TESTS L $ L $ L $ L $ L $ L $ PERIODONTICS $ ORAL AND MAXILLOFACIAL SURGERY $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ SCHEDULE A (OS) Prince Edward Island (Effective Date: May 1, 2016) Version 1.0 Page 2 of 4

16 71211 $238.20 71219 $166.31 72111 $241.01 72119 $143.29 72211 $345.58 72219 $207.34 72221 $476.38 72229 $286.33 72231 $525.41 72239 $315.66 72311 $110.99 72319 $62.95 72321 $209.81 72329 $125.

5 SCHEDULE A Code Lab. O. Surg $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ ADJUNCTIVE GENERAL SERVICES NIHB Sedation and General Anaesthesia Policy must be met. Please refer to the Provider Website: for information on the NIHB dental policies $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ SCHEDULE A (OS) Prince Edward Island (Effective Date: May 1, 2016) Version 1.0 Page 3 of 4

22 79701 $530.72 79702 $522.86 9.0 ADJUNCTIVE GENERAL SERVICES NIHB Sedation and General Anaesthesia Policy must be met. Please refer to the Provider Website: http://www.provider.express-scripts.

6 SCHEDULE A Code Lab. O. Surg $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ SCHEDULE A (OS) Prince Edward Island (Effective Date: May 1, 2016) Version 1.0 Page 4 of 4

60 92435 $178.60 92436 $178.60 92437 $178.60 92438 $178.60 92441 $100.79 92442 $147.93 92443 $200.51 92444 $245.99 92445 $245.99 92446 $245.99 92447 $245.99 92448 $245.99 92451 $138.

7 SCHEDULE B All Procedures in Schedule B have a Predetermination Requirement Code Lab O. Surg 0.0 DIAGNOSTIC 0.1 EXAMINATIONS Maximum 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. Specialist Examinations and Diagnosis - Complete 1 in any 60 months When a specialty complete examination is adjudicated, it eliminates specialty limited examination within the same specialty in that twelve (12) month period $ LABORATORY TESTS When submitting requests of laboratory tests/analysis, a copy of the laboratory report is required L $ L $ DIAGNOSTIC CASTS, UNMOUNTED $ $ PERIODONTICS Management of Oral Disease Eligible once (1) in any twelve (12) month period $ $ $44.14 Periodontal Splint or Ligation, Provisional, Extra Coronal $ $ $ $ $ ORAL AND MAXILLOFACIAL SURGERY $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ SCHEDULE B (OS) Prince Edward Island (Effective Date: May 1, 2016) Version 1.0 Page 1 of 2

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

8 SCHEDULE B All Procedures in Schedule B have a Predetermination Requirement Code Lab O. Surg $ $ $ $ $ ADJUNCTIVE GENERAL SERVICES NIHB Sedation and General Anaesthesia Policy must be met. Please refer to the Provider Website: for information on the NIHB dental policies $ $ I.C I.C. SCHEDULE B (OS) Prince Edward Island (Effective Date: May 1, 2016) Version 1.0 Page 2 of 2

0 ADJUNCTIVE GENERAL SERVICES NIHB Sedation and General Anaesthesia Policy must be met.

Quick Reference for Denti-Cal Providers

Quick Reference for Denti-Cal Providers (This is a summary of key information and requirements of the Denti-Cal program. It is not meant to replace the detailed information in the Denti-Cal Provider Handbook.)