CDCP Oral Health Provider Newsletter Vol. 2 – November 4, 2025

Canadian Dental Care Plan: Oral Health Provider News

This is your periodic oral health provider update to help keep you and your staff informed of the latest Canadian Dental Care Plan (CDCP) news.

CDCP Statistics at a glance as of September 30, 2025:

• Close to 3 million Canadians have received services
• Over 27K eligible oral health-providers are participating in the CDCP
• More than 5.5 million Canadians have been deemed eligible for CDCP services

CDCP statistics are updated on a monthly basis and are found on the Government of Canada CDCP statistics webpage.

Commercial laboratory fees reimbursement update

As of October 17, 2025, reasonable & customary amounts are now applied to commercial laboratory fees for CDCP claims. Consult the How are commercial laboratory costs calculated FAQ for details.

Member Eligibility – Change in coverage

Member eligibility and/or coverage level under the CDCP may change over the course of a benefit period as a result of additional review/reassessment based on tax filing information, voluntarily withdraw from the CDCP, etc.

As a CDCP client’s coverage under the plan can change at any time during the benefit period; it is important and also your responsibility to validate a CDCP client’s coverage at each visit and before providing and billing for services or treatments.

If you have questions related to your CDCP client’s coverage please call Sun Life’s CDCP Contact Centre at 1-888-888-8110.

If your CDCP clients have questions about their eligibility under the plan, they can call Service Canada at 1-833-537-4342 (TTY: 1-833-677-6262).

Consult the FAQ for more details on “What if there has been a change in coverage for my CDCP clients and they are in the middle of treatment?”.

Approved preauthorization submitted by one provider specialty but performed by a different provider specialty

In cases where a preauthorization has been submitted, is approved and is valid for a CDCP client under one provider specialty (e.g. general practitioner), but the client chooses to complete the service with another provider specialty (e.g. denturist), the provider performing the treatment does not need to restart the preauthorization process unless their treatment plan for this CDCP client is different from what was originally submitted.

For example, a denturist would not need to submit a new preauthorization, if a preauthorization was already approved and is still valid under a general practitioner’s procedure code (e.g. complete upper denture) for the same treatment.

Sun Life will review and pay the claim using the equivalent code for denturists.  Note: the claim would be paid based on the CDCP Benefit Grid for Denturists, in this example, and the CDCP client’s coverage applicable at the time the service was rendered, which could be different than what is indicated in preauthorization Explanation of Benefits.

How to use the CDCP Dental Benefits Guide

The following example is provided to support oral health providers and their staff in navigating through the CDCP Dental Benefits Guide to understand the terms and conditions and policies, including criteria, guidelines and limitations, under which the CDCP covers oral health care services for eligible CDCP clients.

Example: Crowns

Follow these steps to navigate through the CDCP Dental Benefits Guide to find policies related to the administering of crowns to an eligible CDCP member.

• Find your service of interest. From the Canadian Dental Care Plan – Dental Benefits Guide homepage scroll to the ‘On this page’ section and select the desired service. For this example, we will use crowns which is found under ‘6.2 Restorative services.’
• Select the specific treatment. Under ‘In this section’, select ‘6.2.5 Crowns’ to view important information regarding crowns.
• Take note of the information regarding the treatment.
  • ‘General Principles’. This section summarizes the terms of coverage.
  • ‘Eligibility Criteria’. This section lists the eligibility and restorability criteria required for the tooth to be considered for coverage. This can be used as a checklist to ensure the tooth meets the criteria prior to submission. Please note this is not an exhaustive list and Sun Life also evaluates using the CDCP’s internal processes and clinical criteria.
  • ‘Frequency limitations for crowns.’ This section describes the coverage frequency limits.
  • ‘Preauthorization documentation requirements for restorative services’. This section outlines the documents required for Sun Life to evaluate the treatment. This can also be used as a checklist to ensure all required documentation is included. If information is missing, it may be requested by Sun Life and/or the submission will be denied.
• Need additional information? Consult ‘7.0 Appendices’ at the bottom of the page for more information, including:
  • CDCP Dental Benefit Grids for a list of eligible procedure codes
  • Payment and reimbursement
  • Preauthorization reconsideration process
  • Claims verification program
  • Exclusions 

Explanation of Benefits: N05 code explained

• N05 is a narrative that Sun Life generates when an oral health provider submits a claim for a service that is not covered by the CDCP. For example, if an implant is submitted (which is considered an exclusion under the CDCP) the claim or preauthorization will produce a decline. The oral health provider would receive the following message N05: This expense is not covered under your benefits plan.
• Providers should continue to consult the CDCP Dental Benefits Guide and the CDCP Dental Benefit Grids for details on what is covered and which procedure codes are under the plan.