Dental Provider Enrolment Form Page 2
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2By completing and signing this Dental Provider Enrolment form you will become a Provider under the NIHB Program (as defined herein)
(the “Provider”) and will be given a unique Provider Number. This unique Provider Number will allow you to submit claims directly to
Express Scripts Canada for payment for services provided to Clients who are eligible for dental benefits under Health Canada’s NIHB
Program.
Upon the submission of a claim as a Provider, you will be subject to the Terms and Conditions of the NIHB Program, the
Express Scripts Canada NIHB Dental Claims Submission Kit (the “Kit”), and the NIHB Dental Benefits Guide (the “Guide”). Both
documents are located on the NIHB Claims Services Provider Website at
Please note the Kit and the
Guide are updated regularly. It is the Provider's responsibility to be in possession of the current version of both the Kit and the Guide.
Revisions are also noted in the NIHB Dental Newsletter which is also posted on the NIHB Claims Services Provider Website.
As signatory to this Enrolment form, you will be responsible for all services billed and paid by Express Scripts Canada to the
unique Provider Number assigned to your application regardless of the corporate structure of the clinic from which you
operate. A submission of a claim under your unique Provider Number indicates your understanding and acceptance of these
Terms and Conditions. In addition, Providers attest to their enrolment and good standing with their respective Dental Provider
Province/ Territory Licensing Body.
Terms and Conditions are, but not limited to:
•
Provider licensure and eligibility requirements;
•
Client eligibility requirements;
•
Coordination with other health plans;
•
Documentation submission process and requirements;
•
Benefits and applicable limitations;
•
Requirements for Dental Providers on the use of treatment codes and standard definitions;
•
Administrative provider audit program which includes an on-site audit program; and,
•
Maintenance of relevant documentation and records to support your claims.
The term of this enrolment shall commence on the effective date (start date) of the unique Provider Number issued by
Express Scripts Canada. Express Scripts Canada may serve the Provider a written notification of termination of Providers’
enrolment hereunder. Please refer to the Kit for further details.
_______________________________________________
Provider No.
_______________________________________________
_________________________________________________
Contact Name
Dental Provider’s Original Signature (NO STAMPS)
________________________________________________
_________________________________________________
Prepared By
Phone No.
Express Scripts Canada/ March 2013-Version 3.0
DENTAL PROVIDER ENROLMENT FORM NIHB PROGRAM
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