The CDCP coordinates benefits for many dental services with Ontario programs like ODSP and Health Smiles but you should know where to file first in order to ensure you get the maximum benefit.
The programs the CDCP (Canadian Dental Care Program) works with are Health Smiles Ontario, Ontario Disability Support Program (ODSP), and Ontario Works. The Ontario Seniors Dental Care Program (OSDC) doesn’t work with the CDCP to coordinate benefits. It is managed by Public Health Units.
Each program is managed by a different group so it can be daunting to figure out who will pay for dental services, especially if you are enrolled in more than one program. The government has set up a tiered structure to better coordinate services.
Tiered Service Structure for Programs
The CDCP is the FIRST TIER of payment for dental services for both the Healthy Smiles Ontario and the ODSP programs. That means all requests for payment will be sent to the CDCP first. Payment requests for services unpaid by the CDCP Healthy Smiles and ODSP can be made to the other two programs. Both are equally secondary payers.
⚠️ The Ontario Works program is managed by municipalities and First Nations communities through local offices. Local offices will need to be contacted individually to coordinate benefits. A tool to find local offices is here.
Providers Do the Paperwork
🎉 Great News for Patients!
Dental patients don’t submit claims forms to the various program administrators. Providers are responsible for filing paperwork with the CDCP, Healthy Smiles Ontario, and the ODSP. Providers will need to file claims or pre-authorizations to the CDCP first and then file any remaining claims with the other providers. Pre-authorizations must be in place before the appointment for service.
Understanding Third-Party Providers
☀️ Sun Life – CDCP Administrator
It’s important to know that claims and preauthorizations aren’t handled directly by the CDCP and coordination isn’t managed directly by the Ontario programs. The CDCP is managed by Sun Life so all claims will go through that entity. Sun Life will send an explanation of benefits with the amount covered under the CDCP.
🔗 Accerta – Ontario Administrator
Accerta is the third-party dental administrator for Ontario. It is the entity responsible for coordinating benefits and coverage between Healthy Smiles and the ODSP and the CDCP.
The Process of Getting Reimbursed
Even though providers are the ones handling this part of the process, it is helpful for dental patients to understand how the system works:
Sun Life Processing
Claims and pre-authorizations will be sent to Sun Life first and it will determine how much is covered. It will send the provider an explanation of benefits with the amount covered.
Secondary Claims
The provider then must send a claim to Accerta for any remaining uncovered amount left by the CDCP. The claim must be sent within 30 days of the dental service to be honored. Providers are entitled to ask for amounts not covered by the CDCP for patients enrolled in multiple programs. There are rules and maximum amounts allowed for claims in the Ontario programs so claims must stay within those guidelines.
⚠️
Important Things to Know
• Frequency Limitations
Patients may end up paying for some services as there are limitations. CDCP and Ontario services have frequency limitations on some services. The CDCP may pre-authorize a dental procedure that is beyond its frequency limitation, but Ontario dental services may not pay the remaining amount unpaid by the CDCP if it’s beyond its frequency rules.
• Balance Billing Restrictions
Also, balance billing isn’t allowed where the Ontario programs are used to supplement the cost of CDCP fees.
• Co-Payment Requirements
While the CDCP offers no co-payment to those whose income makes them eligible for that service tier, others will have a required co-payment even if they are dually enrolled in Ontario’s programs.
💡 Pro Tip: It’s best to get pre-approval from Ontario’s services if you are required to get it from the CDCP to ensure the entire bill will be covered.
🤝 We’re Here to Help
Our office deals with claims for CDCP and Ontario programs regularly. We can explain more of how it works and what you will be expected to pay at the time of service, if anything. We will keep you informed regarding pre-approvals and when services are reimbursed. Talk to us today!