Coordination of benefits between the CDCP and Prince Edward Island’s dental programs

April 2024
Version 1.0

Program Name	Contact Information
Provincial Dental Care Program	Dental Health Services: Phone: 902-368-5460 Toll-Free: 1-866-368-5460 Email: dentalfax@gov.pe.ca
Cleft Palate Orthodontic Funding Program	Cleft Palate Orthodontic Funding Program: Phone: 902-368-4917 Fax: 902-368-4922 Email: dentalfax@gov.pe.ca

Administrator	Contact Information
Health PEI	Dental Health Services: Phone: 902-368-5460 Toll-Free: 1-866-368-5460 Email: dentalfax@gov.pe.ca

What is the payer order between the CDCP and Prince Edward Island’s dental programs?

The CDCP will be the primary payer relative to both Prince Edward Island’s dental programs.

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.

How will the CDCP and Prince Edward Island coordinate benefits?

COB claims submission process — through EDI:

Where patients are eligible for CDCP and dental benefits under a Prince Edward Island’s program, providers will need to:

• Indicate in the patient’s profile of their PMS that the CDCP is the primary payer and the Prince Edward Island’s 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.
  • Providers will then need to send the EOB and an accompanying secondary payer claim form to Health PEI, who will process the claim for any remaining charges according to their program policies.
• In cases where Prince Edward Island’s program fees are greater than CDCP fee rates, providers will be able to seek additional reimbursement from the Prince Edward Island’s program up to the Prince Edward Island’s program fee guide rates, through coordination of benefits.
• Some services covered by the CDCP and by Prince Edward Island’s programs are subject to frequency limits. These frequency limits are not cumulative — neither the CDCP nor the Prince Edward Island’s programs will provide coverage for services beyond their respective frequency limits.
• CDCP clients will continue to be responsible for paying, directly to the provider, any applicable co-payment and any remaining amounts not covered by the CDCP and/or the Prince Edward Island’s dental programs.
• Providers must submit the EOB to Health PEI within 90 days of the date the service has been rendered, either electronically or by paper in accordance with the existing process for the Prince Edward Island’s 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 CDCP for services requiring preauthorization prior to November 2024 and there will be no coordination of benefits.