Coordination of benefits between the CDCP and Ontario’s dental programs

COB claims submission process — through EDI:

Where patients are eligible for CDCP and dental benefits under these two Ontario programs, providers will need to:

• Indicate in the patient's profile of their PMS that the CDCP is the primary payer and the Ontario 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 Accerta.
  • Accerta will process the claim according to the Ontario program's rates and limits as secondary payer.
  • The EOB from Sun Life must be submitted to Accerta within 30 days of the date the service has been rendered either electronically or by paper in accordance with the existing process for the relevant Ontario program.
  • For clients who are eligible for both the CDCP and Healthy Smiles Ontario or the Ontario Disability Support Program, providers may be able to seek additional reimbursement for the portion of their fees that is not covered by the CDCP, up to the maximums in the provincial schedules, through coordination of benefits.
  • Two examples are shown below for illustrative purposes only:
    • Example 1: 2 units of scaling
      • Provider charges: $145.00
      • CDCP pays $134.00
      • HSO/ODSP reimburses $76.02
      • Provider can bill up to $11.00 to HSO/ODSP
      • Total paid to provider = $145.00
    • Example 2: 0.5 units of polishing
      • Provider charges: $35.00
      • CDCP pays $8.75
      • HSO/ODSP reimburses $12.67
      • Provider can bill up to $12.67 to HSO/ODSP
      • Total paid to provider $21.42
      • Provider cannot balance bill the remaining $13.58 to the client.
  • Note: Where providers are coordinating benefits for clients, balance billing is not permitted where the Healthy Smiles Ontario and the Ontario Disability Support Program schedules are used to supplement CDCP established fees.
  • Some services covered by the CDCP and by the Ontario programs are subject to frequency limits. These frequency limits are not cumulative — neither the CDCP nor the Ontario programs will provide coverage for services beyond their respective frequency limits. If a client's frequency limit under an Ontario program has been met by the CDCP coverage, the Ontario program will not provide for any additional frequency.