Claims processing and payment terms (Billing agreement)

The Canadian Dental Care Plan (CDCP) claims processing and payment terms (Billing agreement) sets out the terms and conditions that govern all claims submitted to the CDCP Benefits Administrator - Sun Life Assurance Company of Canada (Sun Life) for payment.

CDCP Parameters

By submitting claims to the CDCP for payment, the following parameters need to be met.

• At the time of treatment, you were licensed and in good standing with the provincial or territorial regulatory body in the jurisdiction in which you practice.
• You made reasonable efforts to validate the identity of the CDCP client through your existing patient intake process.
• You confirmed the CDCP client coverage under the CDCP Dental Benefits Guide Opens external website in a new windoweither through Electronic Data Interchange (EDI), by contacting the CDCP call centre or by using the CDCP Coverage Look-up tool in Sun Life Direct.
• You discussed with the CDCP client which of your recommended services will and will not be covered by the CDCP and what, if any, amounts will be charged to the CDCP client before they agree to care.
• You submitted the claim for direct payment (by direct deposit or cheque from Sun Life) for services covered under the CDCP. The CDCP client cannot submit a claim for reimbursement from the CDCP.

You are encouraged to bill the fees set out in the CDCP Dental Benefit Grids to reduce financial barriers for CDCP clients. However, balance billing up to usual and customary fees will not be prohibited. Where you do not bill in accordance with the CDCP Dental Benefit Grids, CDCP clients will be responsible for the portion of your fees not covered by the CDCP as well as any co-payment, if applicable. CDCP will pay claims quickly (i.e., initially within 48 hours and will move to within 24 hours).

Privacy and Information Sharing Statement

• Information provided to the CDCP will only be used by Sun Life on behalf of Health Canada for CDCP purposes. This information is collected under the authority of the Government of Canada’s Department of Health Act Opens external website in a new windowand will be handled in accordance with the Privacy Act Opens external website in a new window.
• All personal information collected from the CDCP client is confidential and will not be used or disclosed other than for the purposes of administering the CDCP without the CDCP client’s consent, unless in accordance with the applicable privacy legislation.
• As part of the CDCP application process CDCP clients are asked for consent and informed that their personal information may be shared by an oral health provider when considered useful by Sun Life in the context of the program administration, conducting claims verifications and managing claims. This information may include but is not limited to details on the services provided, patient clinical data, payments and x-rays.
• Providers, as required by the laws and regulations in the jurisdiction in which they practice, should continue their processes to obtain patients’ consent for the release of their information or records.
• As a Government of Canada publicly-funded plan, the CDCP is required to have processes and procedures in place to verify the expenditure of taxpayer funds. These procedures are in line with dental benefit industry standards and allow for accountability to Canadians. All claims submitted under the CDCP could be subject to verification.

Payment Terms

By submitting claims to the CDCP’s Benefits Administrator, Sun Life, you agree:

• to submit claims, whether electronically or on paper, to Sun Life for payment that constitute an accurate account of the services you provided and that the charges submitted are in accordance with these CDCP claims processing and payment terms (Billing agreement). Sun Life will only process claims submitted by EDI until November 2024. Starting in November, Sun Life will process both EDI and paper claims;
• to provide any information and documentation related to the claims you submit to the CDCP upon request to Sun Life, as part of the CDCP Claims Verification Program;
• to not hold Sun Life and/or Health Canada liable to you or any third party for any claims, fees, costs, expenses, or any other actions or damages arising out of the provision of the services submitted for payment by the CDCP; and
• to ensure that your employees, agents, and subcontractors comply with the CDCP claims processing and payment terms (Billing agreement) in respect of claims that are submitted on your behalf.

You or Health Canada can choose to end your participation (whether you have signed-up or are participating on a claim-by-claim basis) at any time. You can verify your eligibility to submit claims to the CDCP using the CDCP call centre or by submitting an EDI estimate.  

The CDCP claims processing and payment terms (Billing agreement) will not be unilaterally changed. It may be updated from time to time, with consultation with oral health providers and professional associations in advance. You will be informed of any changes in advance of any changes coming into effect.