ODSP Activism Web Site - Did You Know for ODSP Recipient's

The College of Denturists of Ontario recently published an article in their Denturists Magazine about proper proceedures when providing dentures to ODSP recipients. The College has given permission for the article to be reproduced for easy access by ODSP recipients.

FILING AN ONTARIO DISABILITY SUPPORT
PROGRAM (ODSP) CLAIM
The College of Denturists of Ontario has received a complaint from an ODSP patient whose coverage was not being honoured on the denture services provided by a Denturist. Because the treating Denturist had not filed the claim properly, the claim had been dismissed. Follow-up consultation with the ODSP revealed the process that must be followed, including verification of eligibility, predetermination and coverage verification; and the timeline in which pre-determination and claims must be submitted in order to be eligible for payment.

ODSP Recipients are restricted to a Benefits Provision Schedule, and fees are set. Denturists may provide services beyond those listed in the schedule to recipients, but they may proceed with the work only if the patient agrees to pay the Denturist directly for these services.

Administration Guide for Denturists -

The Ontario Works Assistance (OWA) Recipients Program provides dentures, denture repairs and relines for OWA and ODSP recipients. Coverage is provided as described in the following pages and benefits are limited to the amount indicated for each service.

Coverage Provisions

Fee Schedule	Fee Schedule as outlined in the Schedule of Covered Denture Procedures is limited to the listed fees. Lab fees, exam, cleaning and other services required for the placement, repair, addition or reline of the denture are included in the fees listed.
Reimbursement Level	100%
Eligibility	OWA and ODSP recipients and covered dependents as verified by the plan administrator
Effective Date of Coverage	Coverage takes effect on the date the person became eligible to receive OWA or ODSP
Termination of Coverage	Coverage for a recipient terminates on the earlier of the following dates: 1. The date this program terminates; and 2. The last day of the month in which OWA or ODSP ceases

Eligibility Verification

Eligibility for Denture Coverage
For patients in receipt of OWA or ODSP, service providers are to contact the OWA Dental Unit at 416-440-1505.

Patients in receipt of ODSP should go directly to their dentist/denturist. The dentist/denturist will then follow the current procedure and phone Great West Life to confirm eligibility. Please note that dentures cannot be authorized by the caseworker.

Member ID
Each recipient and/or head of household is assigned a Member ID consisting of nine digits. Each member of the family has a unique Member ID number. This Member ID is essential in order to verify eligibility for benefits.

Telephone Verification
Telephone verification is available Monday to Friday from 8:30 a.m. - 4:30 p.m. with the exception of all statutory holidays. OWA recipients are instructed to advise the dental office personnel of their Member ID at the time of making their appointment, in order that verification can be obtained prior to services being rendered. In the event that the recipient does not have their Member ID, the following information can also be used for eligibility purposes.

Patient's name and date of birth
Relationship of patient to head of household, or
Head of household's Member ID

Once your office administrative staff has been advised of the case number and/or the above information, they should call the OWA Dental Unit at 416-440-1505 to confirm eligibility for benefits.

Verification Number
An eligibility verification number will be provided and should be included on the claim form. Written eligibility verification can be provided upon request, although it is expected that such requests will be very infrequent.

Coverage Verification

Pre-determination of treatment is required under the Denture Services Program.

Coverage is provided for dentures, denture repairs and relines, and is strictly limited to the services described in the section entitled Benefit Provisions. If the service is not listed in this section, it is not a covered service and no benefits will be paid. If the patient requires denture services which are not authorized by this program, the dentist/denturist may proceed with work only if the patient agrees to pay directly for these services.

Dentists/Denturists shall not extra bill the patient for treatments covered under this program. By participating in the OWA Denture Service Plan, the service provider agrees to accept the fees listed in the Schedule of Fees as payment in full.

Claims Submissions
This program is for all eligible claims incurred on or after September 1, 1997.

Important: Claims must be received by the OWA Dental Unit within 90 days of the services being rendered. Otherwise, no benefits will be paid.

A pre-treatment plan must be submitted to the OWA Dental Unit for approval prior to initiating treatment. Service providers will receive an approval form if the pre-treatment plan is approved.

Service providers may wish to include the following information to expedite processing of the pretreatment plan:

the international tooth code numbers for all missing teeth, circling those being replaced by the proposed denture
the date(s) of extraction(s), if known, of the teeth being replaced by the proposed denture
indicate if the proposed denture(s) is an initial appliance(s) or replacement appliance(s), the age, type and condition of the existing appliance
restorative treatment necessary to place the proposed denture(s) for OWA patient only

Once treatment has been approved, treatment must be completed with 90 days or no benefits will be
paid.

A customized OWA Dental Claim form, Standard Dental Claim form or computerized claim form can be submitted to the OWA Dental Unit upon completion of the treatment. Customized OWA Dental Claim forms can be obtained for use by your office by telephoning the OWA Dental Unit at 416-440-1505. A blank claim form will be returned with each claim payment made to your office.

The customized claim form will have the group policy number preprinted. Part 2 Participant information must be completed in its entirety. If using a standard or computerized claim form, please ensure that all information requested on the OWA dental claim form is included on the form being used by your office.

In all cases, benefits will be paid to the service provider, not the participant. In order for your office to receive payment, patients must sign Part 2 of the claim form as acknowledgement of services rendered.

Please mail completed claim forms to:
OWA Dental Unit
The Great-West Life Assurance Company
P.O. Box 4076
Postal Station A
Toronto, ON M5W 3A3

Benefit Provisions
Coverage is provided for the services listed in the Schedule of Covered Denture Procedures when they are required and approved.

General Limitations
No benefits will be paid for:

Expenses that are prohibited from the coverage by law
Services that are not listed in the Schedule of Covered Denture Procedures
Expenses arising from war, insurrection or voluntary participation in a riot

Social Services will apply and administer the Denture Service Program in compliance with the requirements for the Ontario Human Rights Code. In particular Social Services will apply and administer the Program in a manner that ensures that the denture services that are provided are available, with necessary accommodation, to meet the needs of applicants who are disabled as defined by the Ontario Human Rights Code.

Schedule of Covered Denture Procedures

	SERVICE	FEE ³
Dentures	Complete upper & lower	941.00
	Complete upper	469.00
	Complete lower	577.00
	Partial upper	482.00
	Partial lower	506.00
	Partial upper & lower	890.00
	Complete upper & partial lower	1,351.00
	Complete lower & partial upper	1,351.00
Replacement of denture(s) is limited to one in a five-year period. Complete/partial overdentures are not a covered benefit. Partial denture reimbursement is limited to a maximum of the combined fee if the opposing partial was inserted within the previous nine months.
Repairs	Minor repair to existing denture	Up to 58.00
Limited to a maximum of $88 per denture per 12 consecutive months.
Additions/Repairs	Add one tooth	91.00
	Add two teeth or more	131.00
	Add one tooth & clasp	200.00
	Add two teeth or more & clasp	215.00
Replacement of existing denture(s) will not be considered within six months from date of repair/addition.
Reline	Complete upper	141.00
	Complete lower	152.00
	Partial upper	149.00
	Partial lower	161.00
Relines are limited to once every 36 consecutive months. Relines within three months of insertion are not covered. Replacement of existing denture(s) will not be considered within six months from date of reline.
Note: ³ Lab fees, exam, cleaning and other services necessary for the placement, repair, addition, or reline of the denture are included in the fees. Should you wish to record lab fees separately, use code 99111 (commercial) or 99333 (in office).

The above article was extracted from:
College of Denturists of Ontario
COLLEGE CONTACT
VOLUME 13 - 17 February 2006
http://www.denturists-cdo.com/images/pdf/ContactFebruary06.pdf

info@denturists-cdo.com
180 Bloor St. W. #903
Toronto On
M5S 2V6
416.925.6331 / 1.888.236.4326

This web page is posted and maintained by:
Malcolm Dilts
Midland, Ontario
email: mm@magmac.ca
If you have arrived at this page from another site please visit the ODSP Support & Activism Site

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This page updated July 18, 2006