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

November 2024
Version 2.0

Program Name	Contact Information
BC 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.
• SPDR’s dental programs will be the secondary payer.

How will the CDCP and SDPR dental programs coordinate benefits?

• The claim should be submitted to CDCP first, though Sun Life. Sun Life will generate an Explanation of Benefits (EOB) that will show the eligible amount covered under the CDCP (Total Payable to Provider).
• Providers will then need to submit the claim to Pacific Blue Cross as secondary payer within 12 months of the date the service has been rendered, either electronically or by paper, for any remaining amounts, and the claim will be processed in accordance with SDPR's dental program policies.
• 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, as prescribed by SDPR's dental program fee schedules that outline eligible procedures, rates, and limits.
• Some services covered by the CDCP and by SDPR's dental 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: the CDCP provides 4 units of coverage for a specific procedure code, and the BC Healthy Kids program covers 2 units for the same procedure code. If a patient is covered by both the CDCP and BC Healthy Kids and receives 6 units of treatment under this procedure code, the CDCP and BC 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.

What if services require preauthorization under the CDCP?

• Some services under the CDCP will require prior approval through preauthorization before the treatment is confirmed for coverage under the plan. Certain services always require preauthorization, and services above CDCP frequency limitations can also be requested through preauthorization.
• CDCP is accepting preauthorization requests effective November 1, 2024.
• Providers should refer to the CDCP Dental Benefits Guide for services covered by the CDCP and the policies, including criteria, guidelines and limitations, as well as the CDCP Dental Benefit Grids for the list of procedure codes that always require preauthorization - under "Schedule B" or identified with a "P". This also includes treatment for services available without prior approval, but that would be above established frequency limits.
• Oral health providers need to submit all required and relevant documentation available to support the request directly to Sun Life. Please refer to the CDCP Dental Benefits Guide for documentation requirements.
• If a service requires preauthorization under the CDCP, the preauthorization request for that service must always be submitted to the CDCP, regardless of whether the service is covered or has been preauthorized by another federal or provincial dental program.

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 factsheet is only to guide the coordination of benefits between the CDCP and SDPR's dental programs.

Note: The federal age of majority is 18 years of age, whereas in British Columbia the age of majority is 19 years of age. All people covered by SDPR's dental programs aged 18 years and over must apply to the CDCP if they meet all the CDCP eligibility criteria.

Resource:

For more guidance on the claims submission process for CDCP, including preauthorization, post-determination, and reconsideration steps, please refer to the Sun Life claims submission information resource.