Coordination of benefits between the CDCP and the Northwest Territories’ dental programs

April 2024
Version 1.0

What is the payer order between the CDCP and the Northwest Territories’ dental programs?

The CDCP will be the primary payer relative to both of the Northwest Territories’ 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 the Northwest Territories coordinate benefits?

COB claims submission process — through EDI:

Where patients are eligible for CDCP and dental benefits under a Northwest Territories’ program, providers will need to:

• Indicate in the patient’s profile of their PMS that the CDCP is the primary payer and the Northwest Territories’ 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 the Northwest Territories’ third-party administrator (Alberta Blue Cross). If any charges remain, Alberta Blue Cross will process the claim according to Northwest Territories’ program policies.
  • The EOB from Sun Life must be submitted to Alberta Blue Cross within 12 months of the date the service has been rendered, either electronically or by paper in accordance with the existing process for the relevant Northwest Territories’ program.
• Current fee schedules for the Northwest Territories’ programs and the CDCP are similar for many services. In cases where the Northwest Territories’ program fees are equal to or lower than CDCP fee rates, there will be no additional reimbursement on fees. Where the Northwest Territories’ program fees are higher, the Northwest Territories’ program will reimburse up to the Northwest Territories’ program fees.
• Some services covered by the CDCP and by the Northwest Territories’ programs are subject to frequency limits. These frequency limits are not cumulative — neither the CDCP nor the Northwest Territories’ programs will provide coverage for services beyond their respective frequency limits. If a client’s frequency limit under a Northwest Territories' program has been met by the CDCP coverage, the Northwest Territories' program will not provide for any additional frequency.
• CDCP clients will continue to be responsible for paying, directly to the provider, any applicable co-payment and any remaining amounts for services not eligible for coverage by the CDCP and/or under a Northwest Territories' 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.