Coordination of benefits between the CDCP and Nunavut's territorial Extended Health Benefits program
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 Nunavut’s territorial Extended Health Benefits (EHB) program, as 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 |
|---|---|
| Extended Health Benefits (EHB) | Nunavut Health Insurance Programs Office |
| Administrator | Contact Information |
|---|---|
| Nunavut Department of Health | Nunavut Health Insurance Programs Office |
What is the payer order between the CDCP and Nunavut's territorial Extended Health Benefits program?
- The CDCP will be the primary payer relative to Nunavut’s Extended Health Benefits program.
- Nunavut will be the secondary payer.
How will the CDCP and Nunavut coordinate benefits?
- The claim should be submitted to the CDCP first, through Sun Life. Sun Life will generate an Explanation of Benefits (EOB) that will show what amount is covered under the CDCP (Total Payable to Provider).
- Clients will have to pay, directly to their provider, the portion of the invoice not reimbursed under the CDCP, including any applicable co-payment.
- Eligible members of the Extended Health Benefits program may then seek reimbursement for any amounts not covered by the CDCP, up to an annual limit of $1,000, by submitting the EOB or other invoices/receipts as appropriate to the Extended Health Benefits program for payment consideration according to program policies, as the secondary payer.
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.