Coordination of benefits between the CDCP and Prince Edward Island’s provincial dental programs

November 2024
Version 2.0

Program Name	Contact Information
Provincial Dental Care Program	Dental Health Services: Phone: 902-368-5460 Toll-Free: 1-866-368-5460 Email: dentalfax@gov.pe.ca
Cleft Palate Orthodontic Funding Program	Cleft Palate Orthodontic Funding Program: Phone: 902-368-4917 Fax: 902-368-4922 Email: dentalfax@gov.pe.ca

Administrator	Contact Information
Health PEI	Dental Health Services: Phone: 902-368-5460 Toll-Free: 1-866-368-5460 Email: dentalfax@gov.pe.ca

What is the payer order between the CDCP and Prince Edward Island’s provincial dental programs?

The CDCP will be the primary payer relative to both Prince Edward Island’s provincial dental programs.

Prince Edward Island will be the secondary payer.

How will the CDCP and Prince Edward Island coordinate benefits?

• The claim should be submitted to 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 EOB to Health PEI, as the secondary payer, within 90 days of the date the service has been rendered, either electronically or by paper, and the claim will be processed in accordance with Prince Edward Island's program policies.
• In cases where Prince Edward Island's program fees are greater than the CDCP's fees, providers will be able to seek additional reimbursement from the Prince Edward Island program up to the Prince Edward Island's program 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 Prince Edward Island's programs are subject to frequency limits. These frequency limits are not cumulative - neither the CDCP nor Prince Edward Island's programs will provide coverage for services beyond their respective frequency limits.
• 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 Prince Edward Island's provincial dental programs.

What if services under CDCP require preauthorization?

• Some services under the CDCP 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.

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.