Coordination of benefits between the CDCP and Nova Scotia's dental programs
April 2024
Version 1.0
This fact sheet is intended to provide information on the approach to coordination of benefits between the Canadian Dental Care Plan (CDCP) and the Nova Scotia dental programs noted below.
Information on coordination of benefits between the CDCP and the Nova Scotia Department of Community Services' programs will be issued at a later date.
Note: Individuals with private insurance are not eligible for the CDCP, and therefore there would be no coordination of benefits with the CDCP. Should clients have dental benefits through a private plan, then providers must not submit claims to the CDCP.
| Program Name | Contact Information |
|---|---|
| Individuals with Special Needs Health Program | Green Shield Canada on behalf of the Department of Health and Wellness Toll-free: 1-833-739-4035 |
| Children's Oral Health Program | |
| Cleft Palate-Craniofacial Program | |
| Maxillofacial Prosthodontics Program | |
| Oral and Maxillofacial Surgery Program |
| Third-Party Administrator | Contact Information |
|---|---|
| Green Shield Canada |
|
What is the payer order between the CDCP and Nova Scotia dental programs?
The CDCP will be the primary payer relative to Nova Scotia's dental programs, but providers have the choice of billing the Maxillofacial Prosthodontics Program or the Oral and Maxillofacial Surgery Program first instead, if services are eligible.
How do providers submit CDCP claims to Sun Life?
Submitting claims under the CDCP will be done in the same way you are doing now with other insurance plans, so the process will be very familiar and easy.
Claims and CDCP client eligibility verification can be submitted through CDAnet, CDHAnet, and DACnet using oral health providers' existing Practice Management Software (PMS).
For more information on the claims submission process for CDCP, please consult the Sun Life claims submission information document.
Please note that before November 2024, the CDCP will only accept electronic claims submission through Electronic Data Interchange (EDI). If a provider does not have EDI capability, they will be unable to seek reimbursement from Sun Life until November 2024 and will not be able to coordinate benefits with a secondary payer. Please contact the Nova Scotia dental programs directly to discuss options.
How will the CDCP and Nova Scotia coordinate benefits?
COB claims submission process — through EDI:
Where patients are eligible for CDCP and dental benefits under a Nova Scotia program, providers will need to:
- Indicate in the patient's profile of their PMS that the CDCP is the primary payer and the Nova Scotia program is the secondary payer.
- Submit the claim through EDI:
- The claim will automatically go to Sun Life first. Sun Life will generate an Explanation of Benefits (EOB) that will show the eligible amount covered under the CDCP (Total Payable to Provider).
- Make sure to indicate Pay to Provider, Assignment of Benefits, or equivalent (depending on the software) in your PMS — otherwise, your claim submission will be rejected by Sun Life. You will have to choose to assign benefits in your PMS and resubmit your claim.
- If the provider's PMS is set up to automatically submit COB to the secondary payer, the PMS will then send the EOB to Nova Scotia's third-party administrator (Green Shield Canada). If any charges remain, Green Shield Canada will process the claim according to Nova Scotia's program policies.
- The EOB from Sun Life must be submitted to Green Shield within 6 months of the date the service has been rendered, either electronically or by paper in accordance with the existing process for the relevant Nova Scotia program.
- In cases where Nova Scotia's program fees are equal to or lower than CDCP fee rates, there will be no additional reimbursement on fees. Where Nova Scotia's program fees are higher, Nova Scotia's program will reimburse up to the Nova Scotia program fees.
- Some services covered by the CDCP and by Nova Scotia programs are subject to frequency limits. These frequency limits are not cumulative — neither the CDCP nor the Nova Scotia programs will provide coverage for services beyond their respective frequency limits. If a client's frequency limit under a Nova Scotia program has been met by the CDCP coverage, the Nova Scotia program will not provide for any additional frequency.
- CDCP clients will continue to be responsible for paying, directly to the provider, any applicable co-payment and any remaining amounts for services not eligible for coverage by CDCP and/or under a Nova Scotia program.
More details concerning updates to the COB process effective November 2024 will be shared in the coming months.
What if services require preauthorization?
CDCP will start accepting requests for preauthorizations effective November 2024. There is no coverage under the CDCP for services requiring preauthorization prior to November 2024 and there will be no coordination of benefits.
What else do providers need to know?
- If a claim is submitted to a Nova Scotia program and deemed eligible for coverage, providers may not charge any amount to the patient, as there is no balance billing permitted for provincially insured services, as per the Health Services Insurance Act.
- Providers may bill patients for services deemed ineligible under the Nova Scotia program or exceeding the frequency limit of the program.
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