Which Services Need CDCP Preauthorization? How to Submit Requests

CDCP preauthorization started on November 1, 2024, a few months after the Canadian Dental Care Program began in May 2024. This gap created a backlog, as many patients needed procedures that required authorization. 

At the launch, 74% of dentists reported seeing patients needing these procedures, with most planning to submit around 24 requests each. The Canadian Dental Association and local dental organizations pushed for improvements to the preauthorization process. 

As a result, the federal government made changes to clarify the CDCP Benefits Guide and simplify the required documentation. On November 16, 2024, the CDCP Look Up Tool was made available to more dentists, not just those registered for the CDCP.

This article outlines which services require approval, the required documents, and how to correct common mistakes that can lead to denials.

What is the Canadian Dental Care Plan Preauthorization?

CDCP preauthorization is a request for coverage that must be submitted before treatment begins. Sun Life handles these requests in accordance with CDCP rules and Health Canada’s clinical criteria, which focus on essential treatments for active dental issues such as cavities, gum disease, and root problems. 

If a procedure requires preauthorization, it must be approved first, except in rare emergency cases where treatment can be reviewed afterward. 

Since November 1, 2024, the government has introduced this process as part of the Canadian Dental Care Plan, allowing oral health providers to submit requests for these approvals.

Which CDCP Services Require Preauthorization?

Services that require Canadian Dental Care Plan preauthorization include crowns, certain endodontic treatments, sedation beyond basic levels, initial placements of partial dentures, and additional scaling units that exceed frequency limits. Here’s a list of those services.

Which Services are Covered Without CDCP Preauthorization?

Canadian Dental Care Plan preauthorization is needed based on how complex a service is and any limits on how often it can be done. Most basic and preventive dental services can be done without prior approval, such as dental exams, cleanings within allowed limits, fillings, standard root canals on front teeth and bicuspids, extractions, and regular X-rays.

It is also important to know that standard root canals on first and second molars do not require preauthorization, which is often misunderstood by providers.

How to Submit a CDCP Preauthorization Request

The Canadian Dental Care Plan preauthorization process differs significantly from private dental insurance. Oral health providers can submit CDCP preauthorization requests to Sun Life either through Electronic Data Interchange (EDI) or by mail.

Here are 5 steps to follow:

Step 1: Gather Documentation

Documentation requirements vary by service, but most preauthorization submissions to CDCP need: a completed claim form, a treatment plan, recent radiographs (within the last 12 months), and a periodontal chart for certain procedures.

Providers should include as much relevant information as possible to help with the evaluation of the request. The CDCP may request additional information and may deny submissions that don’t clearly demonstrate that the eligibility criteria are met.

Crown Preauthorization Documentation

Crown requests often have some of the highest denial rates due to the extensive documentation requirements involved, including:

• A completed claim form (CDA or equivalent).
• Dated periapical and bitewing radiographs taken within the last 12 months.
• A complete periodontal chart with 6 measurements per tooth, dated within the last 12 months.
• A treatment plan detailing both completed and pending treatment needs.

Note that PSR (Periodontal Screening and Recording) for each sextant, along with 6-site measurements for the requested tooth, may be accepted if a complete periodontal chart is not available.

Endodontic Services Documentation

For root canal re-treatment, apicoectomy, retrofilling, and third molar root canals, the following documents are required:

• Completed claim form.
• Treatment plan outlining both completed and pending treatment needs.
• Dated periapical radiographs taken within the last 12 months (only submit a panoramic if periapical imaging is not possible, and include a rationale).
• Complete periodontal chart with six measurements per tooth, also taken within the last 12 months.
• Clinical findings and rationale that support the request.

CDCP preauthorization requests will be denied if there is moderate to severe periodontal disease along with untreated rampant disease. Make sure to treat any active periodontal issues before submitting endodontic preauthorization requests.

Partial and Complete Denture Documentation

For partial dentures, preauthorization is required for initial placements. However, replacements may not need preauthorization if the previous partial denture was funded by the CDCP and the client meets the frequency eligibility criteria. Thus, verify eligibility in the relevant CDCP section and refer to the Dental Benefit Grids.

Initial placements of partial dentures require the following documents:

• Periapical radiographs of the abutment teeth.
• Bitewing radiographs.
• Periodontal chart for the remaining natural teeth.

If radiographs are unavailable, stone models or photographs of the arches may be accepted, along with a rationale explaining why standard imaging could not be obtained.

Note: The treatment plan does not have to be its own document. You can include the necessary information in other submitted materials, as long as all required details are there.

Sedation Services Documentation

For sedation services that require CDCP preauthorization, such as parenteral conscious sedation or deep sedation/general anesthesia, submit:

• Completed claim form.
• Details of planned or proposed treatment.
• A rationale.

However, nitrous oxide, oral sedation, and their combination do not require CDCP preauthorization, provided the 4 sessions per 12 months frequency limit is adhered to.

Step 2: Submit through EDI or Mail

Before submitting, verify the client’s CDCP eligibility using the CDCP Coverage Look-up tool in Sun Life Direct, an EDI estimate, or by calling the Sun Life CDCP Contact Centre at 1-888-888-8110. Confirming coverage is vital for those who are nearing their CDCP renewal date.

To submit the CDCP preauthorization, you need to complete the claim form using an approved type (CDA/CLHIA, ACDQ, CDHA, DAC, or computer-generated). Ensure to include the procedure code for the requested service.

After that, send them via EDI or mail. For mail submissions, send to:  

Sun Life Assurance Company of Canada  

Canadian Dental Care Plan (CDCP)  

PO Box 99865 STND  

Montreal, QC, H3C 0E6

Step 3: Receive Decision

You will receive approval, denial, or a request for more information. Please avoid submitting the same Canadian Dental Care Plan preauthorization request multiple times, as each submission is treated as a new request and may result in processing delays.

Federal employees have distinct preauthorization and coverage rules for the PSDCP. So, review the Public Service Dental Care Plan to ensure you do not submit CDCP requests that apply to the PSDCP.

Why do CDCP Preauthorization Requests Get Denied?

The main reasons for denial of dental preauthorization requests are incomplete documentation, active diseases (such as cavities or gum issues), and failure to demonstrate that the dental work can be restored. The detailed reasons are explained below:

Missing or Outdated Documentation

Many EDI submissions are returned because supporting documents (attachments) do not transmit correctly. If your practice management software cannot reliably send attachments via EDI, consider mailing the preauthorization request along with all required documentation to avoid an automatic “missing documents” response.

In addition, submissions can fail for three main reasons:

• Radiographs being over 12 months old,
• Periodontal charts lack 6 measurements per tooth, or 
• The treatment plan is incomplete.

Therefore, quickly check the documentation checklist for your specific service before submitting. If your request is denied due to missing documentation, collect the required items and resubmit your request with complete information.

Active Biological Disease Not Addressed

For crown requests, the CDCP requires that basic treatment for active caries or periodontal disease be completed before submitting a crown preauthorization. Different service types may have specific prerequisites, so be sure to consult the relevant CDCP section (such as endodontics, dentures, or sedation) and the Dental Benefit Grids for the procedure code you are requesting.

So, you should complete treatment for active disease, update records to show it’s under control, then resubmit with proof of treatment.

Tooth Restorability Criteria Not Met

To get preauthorization for a crown, you need to show that the tooth can be restored. The CDCP will look at coverage if these conditions are met:

• There is no active periodontal disease.
• The crown-to-root ratio is 1:1 or less, as shown on radiographs.
• There is no furcation involvement.
• There is adequate remaining tooth structure, with the planned restoration margin at least 3 mm from the alveolar crest.
• An adequate ferrule of at least 1.5 mm exists.
• The tooth is extensively restored, and the existing structure can no longer support a direct restoration.

The CDCP defines a “restored tooth” differently for teeth that have undergone root canal treatment versus those that have not. 

For premolars and molars that have had root canal treatment, a tooth is considered extensively restored if three or more sides are affected, including both marginal ridges or if the cusp is completely destroyed. For premolars and molars that have not had this treatment, at least five sides must be involved to be classified as extensively restored.

How to Request Reconsideration After a CDCP Preauthorization Denial

Clients have one level of reconsideration available for denied preauthorization within 60 days. This must be submitted by the oral health provider and include new clinical information. The decision will follow the same policies as the initial submission. Once the reconsideration decision is made, it is final and cannot be revisited.

4 steps for initiating a reconsideration request for this government benefit are: 

Step 1: The oral health provider or a parent/guardian for clients under 18 must begin the reconsideration request.

Step 2: Gather new or additional clinical information. This may include updated radiographs, additional periodontal charting, clinical photographs, notes from specialist consultations, or documentation of completed basic treatments that were missing from the original submission. Resubmitting the same documentation without any new evidence will not change the outcome of the request.

Step 3: Submit the request within 60 days from the date of denial. This deadline is strict and must be adhered to.

Step 4: Wait for the final decision. Once a determination is made, no further reconsideration will be available.

Note that items that are considered program exclusions, such as implants and veneers, cannot be reconsidered, regardless of the clinical documentation provided. For Ontario residents with children under 18, Healthy Smiles Ontario may cover services not included in the CDCP.

The bottom line

To sum up, most CDCP preauthorization denials occur for preventable reasons. The main causes of rejected requests include incomplete documentation, outdated radiographs, and unaddressed active disease. By understanding the factors that trigger a denial before submitting a request, you can avoid delays and ensure that patients receive the care they need more quickly.

Disclaimer: This article is intended for general informational purposes only and should not be considered a substitute for advice from a dental professional. Please note that CDCP policies, covered procedure codes, and documentation requirements may change. For the most up-to-date information, please refer to the official CDCP Dental Benefits Guide and Sun Life CDCP provider resources.

FAQs about Canadian Dental Care Plan Preauthorization