6-8 Dental Benefits
PURPOSE
1. To provide a limited range of dental benefits.
PRINCIPLE
2. Persons should not suffer pain or infection caused by dental problems.
3. Dental benefits are generally restricted to the most essential service to relieve pain or infection.
4. Any services not covered by this policy may be performed by the dentist/denturist and billed to the patient directly, if both parties agree, provided that no reimbursement is expected from Social Services.
5. A second dentist may be consulted where this appears to be appropriate.
6. All eligible children receive basic dental services, including some preventive orthodontic services, under the Children’s Dental Care Program.
POLICY
7. All applicants shall be eligible for a range of emergency dental benefits as provided by a dentist or dental surgeon for the relief of pain and infection only.
BENEFITS
8. Adults and Children Not Covered by Children’s Dental Care Program
(i) Diagnostic services
(ii) Emergency services
(iii) Prosthetic services
Persons with a Disability
(i) Diagnostic services
(ii) Emergency services
(iii) Prosthetic services
(iv) Preventive services
(v) Restorative services
Services to persons with a disability may be provided in a hospital when treatment in dental office is not possible.
9. Special Circumstances
Consideration for special circumstances not covered by the guidelines will be given, but only in rare instances will treatment be approved.
10. Diagnostic Services
Limited to the teeth affected by pain or infection, which includes:
(i) Oral examination
(ii) Radiographs
11. Emergency Services
(i) Extraction for toothache or periodontal infection;
(ii) X-rays for diagnosis of conditions causing pain and/or infection;
(iii) Treatment of abscesses, acute necrotic ulceration gingivitis and post-extraction complications (when provided by a dentist other than the one who did the extractions) such as hemorrhage or dry socket;
(iv) Emergency temporary treatment for teeth fractured as the result of an accidental injury (to alleviate pain);
(v) Palliative treatment for conditions causing pain and/or infection (e.g. temporary restoration);
(vi) Denture repairs are limited to items listed in the attached fee schedule (Appendix "A").
12. Preventive or restorative services are not included (except for persons with a disability), e.g. prophylaxis, fillings, restorations. Exceptions to this policy may be made with the approval of the Department when fillings would save a tooth in the smile area, the cost of an extraction and partial denture would exceed the cost of fillings required, and good dental hygiene practice on the part of the client is probable.
13. Persons with a disability that affects ability to provide for regular dental care may receive full basic dental care, including preventive and restorative services, and, if necessary, services may be provided in a hospital.
14. Prosthetic Services
(a) Complete upper or lower dentures may be provided where the extraction of all teeth is necessary to relieve pain and infection.
(b) Partial dentures may be provided in circumstances involving the replacement of lower posterior teeth when a complete upper denture is required, or in cases where teeth in the aesthetic regions need to be extracted.
(c) Approval of partial dentures shall be conditional upon a high probability of successful use for a lengthy period, based on consideration of the following:
(i) Age of patient
(ii) Comparative immunity to caries
(iii) Likelihood of proper hygienic care of the denture
(iv) Attitude of the patient towards wearing the denture
15. Orthodontic Treatment
(a) Some orthodontic treatment for children 12 years and under is provided by the Preventive Orthodontic Clinic of the Children’s Dental Program.
(b) Orthodontic treatment for applicants by a private specialist shall not be approved except where required for the correction of gross functional disability and not for aesthetic purposes. Orthodontic treatment by dentists in general practice will not be approved.
(c) Requests for orthodontic diagnosis or orthodontic treatment require the approval of a designated authority. It will be necessary to forward the dentist’s explanation of the gross functional disability.
PROCEDURE
16. Authorization
(a) Prior authorization is required for all dental benefits provided to clients and their dependents except for emergency services where immediate attention is required. A "Credit Service Authorization Form" is used to provide approval for three distinct types of dental benefits:
Dental Benefits "A" - Authorization for diagnostic and emergency services as outlined under 10 and 11 and Appendix "A" (sections 1 and 2);
Dental Benefits "B" - Authorization for an examination and estimate to be provided on the "Dental Estimate Form". Services are limited to those outlined in Appendix "A" under Diagnostic Services (section 1);
Dental Benefits "C" - Authorization for basic dental treatment or for denture services are limited to those outlined in Appendix "A" and are based on a previously submitted and approved estimate.
(b) Authorization for diagnostic and emergency services ("A") may be provided by the case worker to a maximum of $90 and for examination and estimate services ("B") to a maximum of $60. Authorization for basic dental treatment or for denture services ("C") requires the approval of a designated authority.
(c) The Department may obtain consultation from the Director of Dental Public Health (368-4915).
17. Estimate and Claim Form
(a) The "Social Assistance Dental Benefits Estimate and Claim Form" is a dual purpose form of four copies. Copies 1 and 2 should be submitted when claiming for services provided. Copy 3 is for estimate submission and copy 4 is for the dentist’s/denturist’s records. Instructions for use are listed on the back of the form.
(b) Following payment of claims, copy 2 will be placed in the client’s file at the Social Assistance office.
(c) Estimates must be submitted on the Social Assistance Dental Benefits Estimate and Claim Form (copy 3) to the appropriate office. The form requires the dentist to indicate teeth that are missing.
(d) In addition, information regarding oral hygiene, periodontal condition and long-term prognosis is required. A separate claim form (copies 1 and 2) is required when claiming for diagnostic services provided in relation to the estimate. This form should be submitted with the estimate form.
18. Payment of Claims
(a) Dentists/denturists and oral surgeons should bill the plan in accordance with the fees as set out in Appendix "A" or their usual and customary fees, whichever is the lower amount.
(b) Dentists/denturists who bill for authorized services shall not extra-bill the patient. The only exception when the dentist/denturist may bill the client (other than for services not covered under policy) is the client portion for prosthetic services.
19. Second Opinions
Where a second dentist is consulted to verify a diagnosis and/or treatment plan, any radiographs taken by the first dentist should be obtained to prevent unnecessary additional radiographs.
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