Coordination of benefits between the CDCP and Ontario’s dental programs

April 2024
Version 1.0

This fact sheet is intended to provide information on the approach to coordination of benefits between the Canadian Dental Care Plan (CDCP) and Ontario's 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.

Dental providers that have questions about how Healthy Smiles Ontario and dental benefits under the Ontario Disability Support Program will coordinate with the CDCP should contact Accerta, Ontario's third-party dental administrator.

Program Name Contact Information
Healthy Smiles Ontario

Toll-free: 1-844-296-6306
Toll-free TTY: 1-800-387-5559
TTY: 416-327-4282

Ontario Disability Support Program (ODSP)

Toll free: 1-888-999-1142
TTY: 1-800-387-5559

Ontario Seniors Dental Care Program (OSDCP)

Tel: 416-916-0204
Toll-free: 1-833-207-4435
Toll-free TTY: 1-800-855-0511

Ontario Works (OW)

Ontario Works is administered by municipalities and First Nations communities. A list of Ontario Works offices can be found at this website Ontario Social Assistance Office Finder.

Third-Party Administrator Contact Information

Phone: 416-922-6565
Toll-Free: 1-800-505-7430
Fax: 416-922-4323
Toll-Free Fax: 1-800-467-1839
General Inquiries:

What is the payer order between the CDCP and Ontario's dental programs?

  • The CDCP will be the primary payer relative to all of the Ontario dental programs.
  • Where coordination is possible, Ontario's programs — the Heathy Smiles Ontario Program and the Ontario Disability Support Program — will serve as the secondary payer.

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.

Please note that before November 2024, the CDCP will only accept electronic claims submission through Electronic Data Interchange (EDI). If a provider does not have EDI capability, they will be unable to seek reimbursement from Sun Life until November 2024 and will not be able to coordinate benefits with a secondary payer. Please contact the Ontario dental programs directly to discuss options.

How will the CDCP and Ontario coordinate benefits?

Please consult the information below for the coordination process for each of Ontario's dental programs:

Healthy Smiles Ontario Program and Ontario Disability Support Program

COB claims submission process — through EDI:

Where patients are eligible for CDCP and dental benefits under these two Ontario programs, providers will need to:

  • Indicate in the patient's profile of their PMS that the CDCP is the primary payer and the Ontario 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 provider's PMS is set up to automatically submit COB to the secondary payer, the PMS will then send the EOB to Accerta.
    • Accerta will process the claim according to the Ontario program's rates and limits as secondary payer.
    • The EOB from Sun Life must be submitted to Accerta within 30 days of the date the service has been rendered either electronically or by paper in accordance with the existing process for the relevant Ontario program.
    • For clients who are eligible for both the CDCP and Healthy Smiles Ontario or the Ontario Disability Support Program, providers may be able to seek additional reimbursement for the portion of their fees that is not covered by the CDCP, up to the maximums in the provincial schedules, through coordination of benefits.
    • Two examples are shown below for illustrative purposes only:
      • Example 1: 2 units of scaling
        • Provider charges: $145.00
        • CDCP pays $134.00
        • HSO/ODSP reimburses $76.02
        • Provider can bill up to $11.00 to HSO/ODSP
        • Total paid to provider = $145.00
      • Example 2: 0.5 units of polishing
        • Provider charges: $35.00
        • CDCP pays $8.75
        • HSO/ODSP reimburses $12.67
        • Provider can bill up to $12.67 to HSO/ODSP
        • Total paid to provider $21.42
        • Provider cannot balance bill the remaining $13.58 to the client.
    • Note: Where providers are coordinating benefits for clients, balance billing is not permitted where the Healthy Smiles Ontario and the Ontario Disability Support Program schedules are used to supplement CDCP established fees.
    • Some services covered by the CDCP and by the Ontario programs are subject to frequency limits. These frequency limits are not cumulative — neither the CDCP nor the Ontario programs will provide coverage for services beyond their respective frequency limits. If a client's frequency limit under an Ontario program has been met by the CDCP coverage, the Ontario program will not provide for any additional frequency.

Ontario Works

Dental benefits under Ontario Works are administered by municipalities. Providers will need to contact the clients' local Ontario Works office for details about how the CDCP and Ontario Works dental benefits interact. Providers can use the Ontario Social Assistance Office finder to find contact information for their clients' local Ontario Works office.

Ontario Seniors Dental Care Program (OSDCP)

  • At this time, there is no coordination of benefits between the CDCP and the Ontario Seniors Dental Care Program.
  • The Ontario Seniors Dental Care Program is administered by Public Health Units and not funded on a fee-for-service basis.
  • It is the patient/client's choice whether they wish to access benefits through the Ontario Seniors Dental Care program or the CDCP, and they are encouraged to discuss with their provider the best option for them.
  • Patient's/client's choosing to access benefits through the CDCP may have to pay additional fees if the oral health provider charges more than the CDCP fees and/or if the patient/client agrees to receive dental care that the CDCP doesn't cover.

CDCP clients will continue to be responsible for paying, directly to the provider, any applicable amounts or services not covered by the CDCP and/or Ontario dental programs, based on the guidance provide above.

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 pre-authorizations 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.

Prior to November 2024, where services covered by Ontario's dental programs require preauthorization, the provider should contact Ontario's programs directly.

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