NIHB Handbook (PDF) - First Nations Health Directors Association

8. PROCEDURE FOR APPEALS
An eligible First Nations client, their parent, legal guardian, or representative may initiate an
appeal process when a benefit has been denied through the NIHB Program. In the event that
they are unable, a client may have someone act on their behalf to initiate an appeal process
as long as written authorization is obtained from the person seeking coverage. There are
three (3) levels of appeal available; namely Level 1, Level 2, and Level 3.
For a case to be reviewed as an appeal, a signed note or letter from the client, parent
or legal guardian, accompanied by supporting information from the service provider or
prescriber must be submitted to the NIHB Program. In many cases the service provider
will be required to provide part of the information being requested. The usual information
requested by NIHB is:
1. The condition for which the benefit is being requested;
2. The diagnosis and prognosis, including what other alternatives have been tried;
3. Relevant diagnostic test results; and
4. Justification for the proposed treatment and any additional supporting information.
The client, parent or legal guardian should submit their letter of appeal and supporting
documentation by mail, clearly marked “APPEAL-CONFIDENTIAL”.
Upon receiving the appeal submission, the NIHB Program will arrange to have the case
reviewed by a medical, dental, orthodontic or vision care professional for a decision by
NIHB management. The decision will be made based on the specific needs of the client,
medical justification, the availability of alternatives and NIHB policy. The client, parent or
legal guardian will be provided with a written explanation of the decision made by the NIHB
Program. If the client, parent or legal guardian has not heard within one month of submitting
the appeal, they may contact the Health Canada regional office for an update.
Your Health Benefits n A GUIDE FOR FIRST NATIONS TO ACCESS NON-INSURED HEALTH BENEFITS 31