Coordination of benefits between the CDCP and the Northwest Territories’ dental programs
November 2024
Version 2.0
This fact sheet is intended to provide information on the approach to coordination of benefits between the Canadian Dental Care Plan (CDCP) and Northwest Territories’ territorial dental programs noted below.
Note: Individuals with private insurance are not eligible for the CDCP, and therefore there would be no coordination of benefits with the CDCP. Should clients have dental benefits through a private plan, then providers must not submit claims to the CDCP.
| Program Name | Contact Information |
|---|---|
| Métis Health Benefits | Health Benefits Program: |
| Extended Health Benefits | Health Benefits Program: |
| Third-Party Administrator | Contact Information |
|---|---|
| Alberta Blue Cross | Health Services Provider Relations: |
What is the payer order between the CDCP and Northwest Territories’ territorial dental programs?
The CDCP will be the primary payer relative to both of the Northwest Territories’ dental programs.
Northwest Territories will be the secondary payer.
How will the CDCP and the Northwest Territories coordinate benefits?
COB claims submission process – through EDI:
- The claim should be submitted to the CDCP first, through 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 Alberta Blue Cross. If any charges remain, Alberta Blue Cross will process the claim according to Northwest Territories' program policies.
- Current fee schedules for the Northwest Territories' programs and the CDCP are similar for many services. In cases where the Northwest Territories' programs fees are greater than the CDCP's fees, providers will be able to seek additional reimbursement from Northwest Territories' programs up to Northwest Territories' programs fee guide rates, through coordination of benefits. In cases where program fees are equal to or lower than CDCP fees, there will be no additional reimbursement on 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 not covered by the CDCP and/or Northwest Territories' territorial program.
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 territorial dental program.
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.