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April 24, 2020

Communication to all NIHB Oral and Maxillofacial Surgeons in Alberta

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 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.

ALBERTA NIHB Regional Dental Benefit Grid

Oral and Maxillofacial Surgeons

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.

ALBERTANIHB Regional Dental Benefit Grid

Oral and Maxillofacial SurgeonsSCHEDULE A

SCHEDULE A (OS) Alberta NIHB Regional Dental Benefit Grid (Effective Date: April 1, 2020)Version 1.0 Page 1 of 5

Code Lab O. Surg

01601 $190.98

01204 $66.01

01205 $66.01

01402 $95.5001602 $98.73

02101 $186.5402102 $186.5402121 $64.3802122 $68.9002123 $73.4202124 $77.9402125 $81.31

02111 $27.6002112 $46.5602113 $65.2502114 $83.9202115 $102.6202116 $121.2202117 $139.8402118 $158.4902119 $177.0802120 $186.5002131 $46.5602132 $69.5202141 $27.95

Emergency Examination1 in any 12 months

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.

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

Specialist Examination and Diagnosis - Limited1 in any 12 months

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

Complete Oral Examination and Diagnosis

Specific Examination1 in any 12 months




Code Lab O. Surg

02142 $45.0802143 $62.3602144 $79.10

02601 $105.98

02701 $138.2902702 $142.98

02801 $47.1102802 $47.1102931 $138.2902932 $216.9002933 $224.2302934 $224.23

04311 L $92.4204312 L $92.4204313 L $92.4204314 L $92.4204315 L $92.4204321 L $116.7504322 L $116.7504323 L $116.75

42831 $89.99

71101 $141.2571109 $141.2571201 $277.2571209 $277.2571211 $278.3971219 $278.3972111 $253.5472119 $253.5472211 $306.3172219 $306.3172221 $408.4272229 $408.4272231 $556.8672239 $556.8672311 $92.8472319 $92.8472321 $139.2672329 $139.2672331 $204.2272339 $204.22

Tomography

7.0 ORAL AND MAXILLOFACIAL SURGERY

4.0 PERIODONTICS

0.3 LABORATORY TESTS

Panoramic

Cephalometric




Code Lab O. Surg

74111 $278.4274112 $361.9274121 $334.0974122 $463.9974211 $259.8074212 $389.6974221 $389.6974222 $519.5674611 $320.2274612 $445.4674621 $408.4274631 $320.2274632 $445.4675111 $204.2275112 $204.2275113 $348.0175121 $213.4775122 $334.0975123 $463.9975211 $482.5175212 $603.1775221 $482.5175301 $649.4675303 $649.4676941 $348.0176949 $348.0176951 $106.7376952 $213.4776961 $222.7376962 $250.5879601 $92.8479602 $97.4679605 $97.4679606 $97.4679701 $593.6979702 $593.69

92212 $224.8892213 $337.3192214 $449.7292215 $562.2192216 $674.6092217 $674.6092218 $674.60

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




Code Lab O. Surg

92222 $224.8892223 $337.3192224 $449.7292225 $562.2192226 $674.6092227 $674.6092228 $674.6092301 $77.4092302 $168.4092303 $252.5692304 $336.7492305 $420.9692306 $505.1692307 $505.1692308 $505.1692321 $81.4492322 $168.4092323 $252.5692324 $336.7492325 $420.9692326 $505.1692327 $505.1692328 $505.1692411 $44.5192412 $66.7992413 $89.0892414 $111.2992415 $133.5692416 $155.8692417 $155.8692418 $155.8692421 $28.6792422 $28.6792423 $28.6792424 $28.6792425 $28.6792426 $28.6792427 $28.6792428 $28.6792431 $54.7892432 $76.9892433 $108.4392434 $142.6792435 $161.8692436 $180.7092437 $180.7092438 $180.7092441 $44.51




Code Lab O. Surg

92442 $66.7992443 $89.0892444 $111.2992445 $133.5692446 $155.8692447 $155.8692448 $155.8692451 $151.8292452 $210.1292453 $281.9592454 $351.0792455 $421.5792456 $491.6492457 $491.6492458 $491.64


Oral and Maxillofacial SurgeonsSCHEDULE B

SCHEDULE B (OS) Alberta NIHB Regional Dental Benefit Grid (Effective Date: April 1, 2020)Version 1.0 Page 1 of 3

Code Lab O. Surg

01401 $190.9801603 $190.98

04101 L $79.8504401 L $79.85

04911 $73.7704913 $145.14

33115 $989.8033125 $1,390.4233135 $1,555.3733145 $1,838.1833601 $281.6033602 $422.4133603 $563.2433604 $750.9733605 $88.6133611 $140.7833612 $179.6633613 $269.2533614 $360.3533621 $406.7033622 $595.9333623 $705.7133624 $784.1334111 $514.3234112 $687.4534121 $687.1134122 $799.5234123 $982.5234131 $641.29

0.3 DIAGNOSTIC CASTS, UNMOUNTED

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

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.

Specialist Examinations and Diagnosis - Complete1 in any 60 monthsWhen a specialty complete examination is adjudicated, it eliminates specialty limited examination within the same specialty in that twelve (12) month period.




Code Lab O. Surg


34132 $782.6534133 $1,180.2934134 $713.0334141 $588.7834142 $785.8234151 $852.9334152 $885.2334153 $1,080.8834161 $685.3534162 $925.3634163 $1,180.2934164 $713.0334211 $102.8534212 $186.6034221 $104.8834222 $186.6034223 $282.0034224 $375.3034231 $102.4234232 $186.6034233 $282.0034234 $375.3034241 $118.5834242 $186.6034251 $93.2934252 $186.6034253 $282.0034254 $375.3034261 $93.2934262 $197.0834263 $282.0034264 $375.30

41211 $47.9541221 $47.9541231 $47.95

43211 $85.7243221 $85.7243231 $85.7243241 $85.7243281 $85.72

72511 $185.6872519 $185.68

Periodontal Splint or Ligation, Provisional, Extra Coronal

7.0 ORAL AND MAXILLOFACIAL SURGERY

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




Code Lab O. Surg


72521 $334.0972529 $334.0972531 $445.4672539 $445.4672541 $278.5272551 $371.3973121 $185.6973411 $194.8975302 $649.4675401 $445.4675403 $167.0875411 $445.4675412 $556.8676201 $863.3476301 $863.3479603 $97.4679604 $97.46

94302 $83.9999222 I.C.

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.

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