Coordination of benefits between the CDCP and British Columbia’s dental programs

April 2024
Version 1.0

Program Name	Contact Information
Healthy Kids Program	General Inquiries Healthy Kids - Province of British Columbia (gov.bc.ca)
BC Employment and Assistance (BCEA) Program	General Inquiries Dental coverage - Province of British Columbia (gov.bc.ca)

Third-Party Administrator	Contact Information
Pacific Blue Cross	Toll-free: 1-877-PAC-BLUE Phone: 604-419-2000 Fax: 604-419-2990

What is the payer order between the CDCP and SDPR dental programs?

The CDCP will be the primary payer relative to SDPR 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 SDPR dental programs coordinate benefits?

COB claims submission process — through EDI:

Where patients are eligible for CDCP and dental benefits under a SDPR dental program (Healthy Kids or BC Employment and Assistance Program), providers will need to:

• Indicate in the patient's profile of their PMS that the CDCP is the primary payer and the SDPR dental 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 providers' PMS is set up to automatically submit COB to the secondary payer, the PMS will then send the EOB to Pacific Blue Cross.
  • Pacific Blue Cross will process the claim according to program fee schedules that outline eligible procedures, rates, and limits as second payer.
  • SDPR dental programs may pay the difference between the amount reimbursed by the CDCP and the fees charged by the provider, up to the British Columbia Dental Association fee schedules, according to SDPR dental program fee schedules that outline eligible procedures, rates, and limits.
  • The EOB from Sun Life must be submitted to Pacific Blue Cross within 12 months of the date of service either electronically or by paper in accordance with the existing process for the relevant SDPR dental program.
• Some services covered by the CDCP and by SDPR's programs are subject to frequency limits. These frequency limits are not cumulative — neither the CDCP nor SDPR's dental programs will provide coverage for services beyond their respective frequency limits.
  • Example: CDCP provides 4 units of coverage for a specific procedure code, and Healthy Kids program covers 2 units for the same procedure code. If a patient is covered by both CDCP and Healthy Kids and receives 6 units of treatment under this procedure code, CDCP and Healthy Kids will coordinate fees for the first 2 units, and CDCP will provide coverage for 2 additional units. Neither program would provide coverage for the remaining 2 units.

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 preauthorization requests effective November 2024. Services requiring preauthorization from CDCP prior to November 2024 are not eligible for reimbursement.
• Before November 2024, for Healthy Kids and BCEA, please contact Pacific Blue Cross, directly for preauthorization before providing services.
• After November 2024, preauthorization requests for both CDCP and SDPR dental programs should be submitted at the same time to ensure eligibility and coverage across all programs prior to providing services.

What else do providers need to know?

• Service codes claimed should be for the actual service performed and should not change when coordinating across different programs with different fee grids/supplements/schedules.
• This guide is for coordination between the CDCP and dental programs administered by SDPR only.
• Note: The federal age of majority is 18 years of age, whereas in British Columbia the age of majority is 19 years of age. Healthy Kids Program and BCEA clients aged 18 years must file their own taxes and apply for their own CDCP coverage. They remain eligible for Healthy Kids and BCEA.