Appeals

​When coverage for a benefit has been denied, the client, their parent or guardian, or their representative has the right to appeal the decision. This requires writing a letter of appeal that describes the situation in detail. Appeals must be submitted within 12 months from the date the benefit was denied.

Clients must include the following information in their letter of appeal:

• ​The condition for which the benefit is being registered;

• The diagnosis and prognosis, including what alternatives have been tried;

• Relevant diagnostic test results (e.g., dental x-rays); and

•​ Justification for the proposed treatment and any additional supporting information.


There are two levels of appeal available to Health Benefits clients. If an appeal is denied and there is new information that could support it, clients may escalate the appeal and ask for another review within 30 days of the appeal being denied. All appeal materials should be clearly marked APPEALS – CONFIDENTIAL."

To initiate an appeal call Health Benefits at 1-855-550-5454.

Orthodontics Appeals

In addition to the letter of appeal and supporting documentation, orthodontic appeals should include the following information provided by the orthodontist or dentist:

• Orthodontic Summary Form, with HLD Index results;

• Diagnostic test results, including:

o ​Cephalometric radiographs with associated scale for calibration;

o Frontal and profile photographs;

o Intra-oral photographs depicting the right, left, and anterior occlusal relationships;

o Panoramic radiographs; and

o​ Diagnostic orthodontic models.

• Treatment plan, estimated duration of active and retention phases of treatment, and an outline of billable costs; and

• Signature of parent or guardian, including their Band name and status number.

 Do you have questions?

Contact us at 

HealthBenefits@fnha.ca

or call

1-855-550-5454 (Toll Free)​

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