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ONTARIO WORKS IN PEELSCHEDULE OFEMERGENCY DENTAL/DENTURESERVICES and FEESAdult Emergency Discretionary Dental/Denture PlanRevised: March 28, 2017
TABLE OF CONTENTSADULT EMERGENCY DISCRETIONARY DENTAL AND DENTURE PLAN . 3Who administers the plan on behalf of Ontario Works?3The Adult Emergency Discretionary Dental Plan3What services are covered under the discretionary dental/denture services? 3Who is covered for adult emergency discretionary dental services? 3Who is covered for denture services? 4What policy plan # do I use? 3INFORMATION REQUIRED BY A DENTAL/DENTURE PROVIDER . 4What should the dental provider do?4CLAIMS FOR DENTURES . 5Submitting a Claim:5PLAN DESCRIPTIONS . 6ADULT EMERGENCY DISCRETIONARY DENTAL PLAN - POLICY #51616 . 6EXTENUATING CIRCUMSTANCES . 7Princess Margaret Hospital7CLAIMS SUBMISSIONS. 8RECONSIDERATION FOR CLAIMS DENIED BY GREAT WEST LIFE . 9APPENDIX I - Schedule of Covered Adult Emergency Dental Procedures. C-DC 1APPENDIX II - Schedule of Covered Denture Procedures . C-DC 6
NOTEThe purpose of this fee guide is for Adult Emergency Discretionary Dentaland Denture Plans only and does not include children ages 0-17 years old. Forchildren 17 and under, please refer to Healthy Smiles Ontario (HSO) websitefor information and fee guides.ADULT EMERGENCY DISCRETIONARY DENTAL ANDDENTURE PLANWho administers the plan on behalf of Ontario Works?Great West Life Assurance Company (GWL) administers the adult emergencydiscretionary dental/denture plan on behalf of Ontario Works. Dental providers requestinginformation regarding client eligibility or coverage should contact Great West Life directlyat 1-800-957-9777.The Adult Emergency Discretionary Dental PlanCoverage under this plan is for Emergency Services only. Emergency services are definedas immediate circumstances where the client appears in immediate suffering, requiring careand immediate appropriate treatment to correct the problem.What services are covered under the discretionary dental/denture services?Services and fees are listed in the Ontario Works schedule of dental services and fee guide(Appendix I) and denture services and fees are listed in (Appendix II). Refer to theschedule of services and fee guide to determine which dental/denture procedures arecovered and the amounts that will be paid for the procedure.Who is covered for adult emergency discretionary dental services?The following Ontario Works clients are covered for adult emergency dental services: An applicant/head of household who is receiving Ontario Works assistance; andTheir spouse; and/orTheir dependent children who are 18 years of age and older; orAn 18 year old youth receiving assistance in their own right; orDependent adults 18 years of age or older receiving Ontario Works assistance andwhose parents are receiving assistance from the Ontario Disability Support Program(ODSP).3-
Who is covered for denture services?The following Ontario Works/ODSP clients are covered for denture services: An applicant/head of household who is receiving Ontario Works assistance; andTheir spouse; and/orTheir dependent children who are 18 years of age and older; orAn 18 year old youth receiving assistance in their own right; orDependent adults 18 years of age or older who are receiving Ontario Works assistanceand whose parents are receiving assistance from ODSP; andODSP recipients; and their spouse.What policy plan # do I use?Ontario Works policy plan number for adult emergency dental/denture services and dentureservices for ODSP recipients is #51616. This policy plan number is used when: The client resides in Peel; and Is receiving Ontario Works or ODSP assistance in the Region of Peel.INFORMATION REQUIRED BY A DENTAL/DENTUREPROVIDERWhat should the dental provider do when an Ontario Works client and/or theirdependent is seeking dental care?For adult Ontario Works and eligible ODSP clients service providers should: Refer to the Ontario Works Schedule of dental/denture services and fee guide(Appendix I) and (Appendix II) to determine what procedures are covered and theamounts covered for the procedure.The dental provider must have the following information: A copy of the client’s Statement of Assistance for the current month;The applicant/head of household’s 9 digit Member ID# which is indicated on theStatement of Assistance;The Statement of Assistance in the period covered box must reflect the dates of thecurrent month e.g. 010713 to 310713;The applicant/head of household’s first and last name and their date of birth;The name and date of birth of the family member/patient who is requesting treatment;The patient’s relationship to the applicant/head of household; andA completed Great West Life dental claim form signed by the client which must bereceived by Great West Life within 90 days of services being rendered.4-
What to do if the client does not have their Statement of Assistance:The dental provider must ensure they have the following information: The applicant/head of household’s 9 digit Member ID #The applicant/head of household’s first and last name;Their date of birth;The first/last name and date of birth of the family member who is requesting treatment;Their relationship to the applicant/head of household; andContact and verify with Great West Life that the client is currently eligible forassistance.CLAIMS FOR DENTURESThe dentist/denturist must complete: A pre-determination and authorization of treatment is required for any denture services;and,The provider must wait for written approval prior to commencing any treatment orthe claim will not be paid.Submitting a ClaimService providers must: Submit their claim to Great West Life by mail using the Regional Municipality of PeelMandatory and Discretionary dental/denture benefits claim form; andEnsure their claims are received by Great West Life within 90 days of services beingrendered.Requests for appeal of a claim declined beyond the 90-day submission period must besubmitted to Great West Life in writing providing the reasons for the extension.Providers should not be requesting the client pay upfront as Great West Life will notreimburse a client directly.Claims must be mailed to:The Great West Life Assurance CompanyLondon Benefit Payments255 Dufferin Ave.London, ON N6A 4K15-
PLAN DESCRIPTIONS ADULT EMERGENCY DISCRETIONARY DENTAL PLAN - POLICY#51616Coverage is for Emergency Services only as described on page 3.Benefit ProvisionCoverage is provided for the services listed in the Ontario Works in Peel Schedule ofEmergency Dental/Denture Services and Fees (Appendix I) when they are required as aresult of a dental emergency.If the client requires dental services, which are not authorized by the Ontario Works inPeel’s Schedule of Services and Fees, or fees exceed the maximums as outlined in the FeeSchedule the dentist may proceed with work only if the client agrees to pay directly forservices not covered or the difference in cost for services covered.Coverage VerificationCoverage is provided for emergency services only and is strictly limited to the servicesdescribed in the section entitled “Schedule of Covered Adult Emergency DentalProcedures” (Appendix I). By referring to this section, it can be determined whether or notthe services will be covered. If the procedure code is not listed, then the code is not acovered service and no benefits will be paid.If the client requires dental services, which are not authorized by this program, the dentistmay proceed with work only if the client agrees to pay directly for these services. Ongoingtreatment and/or maintenance treatment are not considered emergency services.Providers should not be requesting the client pay upfront as Great West Life will notreimburse a client directly.If treatment continues over a period of more than one month, verification of eligibility fromGWL must be obtained for each subsequent month.Fee ScheduleCoverage Provision: Ontario Works Fee Schedule as outlined in the Schedule of CoveredAdult Emergency Dental Procedures (Appendix I), is limited to the listed fees. Any otherprocedures required that are not considered emergency services will be at the cost to theclient.Great West Life Assurance Company does NOT approve or verify payment by phone, asthe fee schedule is procedure specific.6-
Reimbursement LevelCoverage Provision: 100% as per the Ontario Works in Peel’s Fee Schedule. Any otherprocedures required that are not considered emergency services will be at the cost to theclient.Co-ordination of Benefits: Claims for services performed for patients who have dentalbenefits under a private dental plan, contract or insurance policy, must be submittedthrough the private plan first. All dental offices must first request payment through theprivate plan. Ontario Works coverage is the second payor if the amount paid by the firstpayor is less than this schedule, or if the first payor declines payment, benefits may becoordinated through this plan.EXTENUATING CIRCUMSTANCESThe following applies to those eligible under the Adult Emergency DiscretionaryDental/Denture Plans.Ontario Works will consider coverage required due to extenuating medical situationsdeemed a medical necessity. Written medical rationale substantiating the requirement mustbe submitted to Great West Life for “consideration”.Examples of extenuating medical circumstances are but not limited to the following: Diabetes;Developmental disabilities (such as Down Syndrome);HIV/AIDS;Radiation of head/ neck;Pre dental treatment prior to heart surgery;Other illnesses that directly impact on the oral health of a client.Princess Margaret HospitalOntario Works has entered into an agreement with Princess Margaret Hospital, Departmentof Dentistry, approving complete oral examinations, cleaning and fluoride trays for patientsreceiving chemotherapy, radiation or bone marrow transplant for their cancer treatment.Effective Date of CoverageCoverage takes effect on the date the person became eligible to receive Ontario Worksassistance.7-
Termination of CoverageCoverage for a client terminates on the earlier of the following dates:1. The date this program terminates; and2. The last day of the month in which the Ontario Works benefits cease.CLAIMS SUBMISSIONSAll claims for discretionary dental procedures are to be submitted to Great West Life on aRegional Municipality of Peel Mandatory and Discretionary claim form. A supply of theRegion of Peel’s Dental Claim forms can be obtained by contacting Great West Life at This claim form has been customized to include the group policy number. The client’sinformation must be completed in its entirety. Once the claim form has been completedwith both the dentist’s signature and the signature of the client, spouse, guardian and/ordependent child 18 years of age or older the form can be sent to Great West Life AssuranceCompany for payment.In all cases, benefits will be paid to the provider of service, not to the client. In order fordental providers to receive payment, the client who requires the service must sign the claimform. The signature of the client, spouse, guardian and or dependent child 18 and over whois an eligible member in the benefit unit is an acknowledgement of services rendered.IMPORTANT: Claims must be received by Great West Life Assurance Company within 90 days ofthe services being rendered; otherwise it cannot be guaranteed that benefits will beconsidered. If a code is listed on a claim form that does not appear in the schedule, the serviceprovider will not be reimbursed. Corrections to codes after they have been submitted to Great West Life will not beaccepted. Great West Life will not approve or verify payment over the phone. Claim forms not completed correctly will be returned to the service provider and mustbe re-submitted and received by Great West Life within the 90-day time limit. Requests for appeal of a claim declined beyond the 90-day submission period must besubmitted to Great West Life in writing providing the reasons for the extension.8-
RECONSIDERATION FOR CLAIMS DENIED BY GREATWEST LIFEIf a claim has been denied by Great West Life a dental provider may submit a request toOntario Works for reconsideration of the claim. The dental provider must submit thefollowing: Reasons for reconsideration;The Claimant’s Explanation of Benefits/Denial letter from Great West Life;Applicant’s member ID#, applicant’s name, patient’s member ID# and name; andDental provider’s name, phone #, and address.Requests for reconsideration of claims denied by Great West Life may be granted on a caseby case basis. Requests for payments because of the difference in costs paid by GreatWest Life and the actual cost charged by the dental provider will not be considered.Requests for reconsideration must be submitted to:Great West Life 1-800-957-9777; orThe Great West Life Assurance CompanyLondon Benefit Payments255 Dufferin AveLondon, ON N6A 4K1Providers are to contact GWL prior to contacting Ontario Works.Service providers may then direct their inquiries to Ontario Works via email at:zzg-owdental-visionrequest@peelregion.ca or call extension (905) 793-9200 ext. 8453.Inquiries should include the following information: 9 digit Member ID# of the applicant and their first and last name;The name of the person who required the dental work;The name of the dental provider and their phone #; andThe reasons for the inquiry.Once a decision to deny a claim has been made by Ontario Works in Peel, the decisionis final.A copy of this plan can be accessed on the Region of Peel’s website ision.htm9-
General LimitationsThis program is for all eligible claims incurred on or after August 1, 1999.1. No other procedures other than what is outlined in the Schedule of CoveredDental/Denture Procedures and Fees will be accepted.2. Dentists/denturists will be reimbursed on an individual dentist basis for frequencylimitation services. The Region of Peel will be applying same dentist to include samedental office.3. Acceptance of client for service is acceptance of fees for procedures as outlined in theRegion of Peel’s Fee Schedule of Covered Dental/Denture guide.No benefits will be paid for:1. Expenses that are prohibited from coverage by law.2. Services that are not listed in the Schedule of Covered Dental Procedures (Appendix I).3. Services that are listed in the Schedule of Covered Dental Procedures (Appendix I)rendered in a non-emergency situation.4. Expenses arising from war, insurrection or voluntary participation in a riot.Copyright“The fees for service in the Dental Schedule for the Dental Plan have been established bythe Regional Municipality of Peel. The Canadian Dental Association is the owner of thecopyright and other intellectual property rights to the USC&LS and the Ontario DentalAssociation is the owner of the copyright and other intellectual property rights in theselection and arrangement of the dental procedure codes and descriptors in the DentalSchedule.”10 -
BENEFIT PROVISION – DCAPPENDIX I - Schedule of Covered Adult Emergency Dental ProceduresThe specialist fee is paid to licensed specialists for services performed within their specialty, when patients arereferred to a specialist by a general dentist.CODE SERVICEFEEGPSPECIALIST 18.93 18.93 22.73 22.73Diagnostic:0120401205Specific examinationEmergency examinationCoverage is limited to one time unit (15 minute interval) only:Radiographs:021110211202113Single periapicalTwo periapicalsThree periapicals 13.30 16.27 20.04 15.96 19.53 24.05021410214202143Single bitewingTwo bitewingsThree bitewings 13.30 16.27 20.15 15.96 19.53 22.18Only 6 radiographs will be considered in 12 consecutive monthsTests:Tests, histological, soft tissue04311Biopsy, by puncture L*04312Biopsy, by incision L* 37.87 37.87 45.44 45.44Tests, histological, hard tissue04321Biopsy, by puncture L*04322Biopsy, by incision L* 88.36 88.33 106.03 106.03The following lab codes below are eligible only in conjunction with codes 04311/04312/0432104322. For all other procedures, lab costs are included in the procedure fees listed in this schedule.A copy of the laboratory invoice or receipt of laboratory payment must be submitted with the claim form forCode 99111. The amount listed on the invoice will be paid in full. For 99333, please submit in-officelaboratory expenses. Laboratory fees must appear immediately below the procedure codes(s) to which theyapply.99111* Commercial Lab Fee99333 * In-office Lab FeeBenefit Provisions – HealthDental care 51616C-DC 1
APPENDIX IBENEFIT PROVISIONS – DCCODE SERVICEFEEGPSPECIALIST 31.56 31.56 37.87 37.87Restorative – Trauma Control:Trauma control, smoothing teeth20111First tooth20119Each additional tooth – same quadrantCoverage is provided only when treatment is rendered within 30 days of an accident.Restorative – Restorations:No coverage is provided for surfaces re-treated within 2 years.Amalgam RestorationsNon-bonded, permanent biscupids and anteriors21211 one surface21212 two surfaces21213 three surfaces21214 four surfaces21215 five surfaces or maximum surfaces per tooth 25.25 55.29 63.12 75.74 75.74 30.29 66.34 75.74 90.88 90.88Non-bonded, permanent molars21221 one surface21222 two surfaces21223 three surfaces21224 four surfaces21225 five surfaces or maximum surfaces per tooth 31.83 63.12 79.02 79.02 79.02 37.87 75.74 94.82 94.82 94.82Bonded, permanent bicuspids and anteriors21231 one surface21232 two surfaces21233 three surfaces21234 four surfaces21235 five surfaces or maximum surfaces per tooth 25.95 55.29 63.12 75.74 75.74 30.29 66.34 75.74 90.88 90.88Bonded, permanent molars21214 one surface21242 two surfaces21243 three surfaces21244 four surfaces21245 five surfaces or maximum surfaces per tooth 31.83 68.12 79.02 79.02 79.02 37.87 75.74 94.82 94.82 94.20Benefit Provisions – HealthDental care 51616C-DC 2
APPENDIX IBENEFIT PROVISIONS – DCCODE SERVICEFEEGPSPECIALISTTooth-coloured RestorationsCoverage is provided for permanent anteriors and bicuspids only.Acid etch/non bonded technique; permanent anteriors23101 one surface23102 two surfaces23103 three surfaces23104 four surfaces23105 five surfaces 44.18 56.80 86.85 86.85 97.20 53.02 68.17 104.20 104.20 116.63Acid/bond technique; permanent anteriors23111 one surface23112 two surfaces23113 three surfaces23114 four surfaces23115 five surfaces 50.49 63.12 94.67 94.67 106.03 60.59 75.74 113.61 113.61 127.24Plastic with/without silver fillings; permanent posteriorsNon bonded permanent bicuspids23211 one surface23212 two surfaces23213 three surfaces23214 four surfaces23215 five surfaces 44.17 79.02 86.85 104.27 104.27 53.02 94.82 104.20 125.11 125.11Plastics with/without silver fillings; permanent posteriorsNon bonded permanent molars23221 one surface23222 two surfaces23223 three surfaces23224 four surfaces23225 five surfaces 50.49 86.85 94.67 113.61 113.61 60.59 104.20 113.61 136.32 136.32Acid etch/bond technique; permanent bicuspids23311 one surface23312 two surfaces23313 three surfaces23314 four surfaces23315 five surfaces 50.49 86.85 94.67 113.61 113.61 60.59 104.20 113.61 136.32 136.32Provisions – HealthDental care 51616C-DC 3
APPENDIX IBENEFIT PROVISIONS – DCCODE SERVICEPermanent posteriors – Bonded permanent molars23321 one surface23322 two surfaces23323 three surfaces23324 four surfaces23325 five surfacesFEEGPSPECIALIST 56.80 94.67 102.50 123.20 123.20 68.17 113.61 123.02 147.84 147.84 63.12 75.74Endodontics – PulpectomyNo coverage is provided for molar teeth.Permanent anteriors and bicuspids32311 one canalEndodontics – Root Canal Therapy:Only 1 root canal procedure is payable per tooth. Coverage is limited to casesinvolving the following teeth: 13, 12, 11, 21, 22, 23, 33, 32, 31, 41, 42 and 43.33111 one canal 252.45 252.45If a pulpectomy was performed on the tooth by the same dentist in the last 3months, the amount payable is reduced by the amount paid for the pulpectomy.8.Surgical:Removals; erupted teeth; uncomplicated71101 single tooth71109 additional tooth, same quadrant 37.87 18.93 45.44 22.73Removals, erupted teeth; complicated71201 single tooth71209 additional tooth, same quadrant 88.36 88.36 106.03 106.03Removal; impactions; soft tissue coverage72111 single tooth72119 additional tooth, same quadrant 88.36 88.36 106.03 106.03Benefit Provisions – HealthDental care 51616C-DC 4
APPENDIX IBENEFIT PROVISIONS – DCCODE SERVICEFEEGP9.SPECIALISTRemovals; impactions; bone coverage- either removal of bone and tooth or sectioning and removal of tooth72221 single tooth 176.7272229 additional tooth, same quadrant 176.72 212.06 212.06Removals, impactions; bone covered, requiring sectioning- removal of bone and sectioning of tooth for removal72231 single tooth 201.9672239 additional tooth, same quadrant 201.96 242.35 242.35Removals; residual roots; soft tissue coverage72321 first tooth72329 additional tooth, same quadrant 75.74 75.74 90.89 90.89Removals; residual roots; bone tissue coverage72331 first tooth72339 additional tooth, same quadrant 88.36 88.36 106.03 106.0375112 Intraoral incision and drainage 38.08 38.08 16.92 29.55 42.19 54.80 67.44 80.07 92.69 105.33 20.31 35.45 50.62 65.76 80.94 96.09 111.23 126.38Adjunctive Services:Conscious sedation; nitrous oxide and oxygen92411 one unit of time92412 two units of time92413 three units of time92414 four units of time92415 five units of time92416 six units of time92417 seven units of time92418 eight units of timeBenefit Provisions – HealthDental care - 51616C- DC 5
BENEFIT PROVISIONS – DCAPPENDIX II - Schedule of Covered Denture ProceduresCODE 30152302523035330153302Complete upper and lower denturesComplete upper dentureComplete lower denturePartial upper denture*Partial lower denture*Partial upper and lower dentures*Complete upper and partial lower denturesComplete lower and partial upper dentures 685.33 418.33 533.04 304.59 320.65 573.73 723.41 723.41 685.33 418.83 533.04 304.59 320.65 573.23 723.41 723.41No coverage is provided for replacement dentures provided within 5 years of aprevious denture.No coverage is provided for a replacement denture if a denture repair/addition orreline procedure was performed on the existing denture within the last 6 months.No coverage is provided for complete or partial overdentures.The amount payable for partial upper and lower dentures combined also applies whenone of the dentures was inserted within the last 9 months.2.Denture Repairs:55101 Minor repair to existing upper denture55102 Minor repair to existing lower denture 42.36 42.36 42.36 42.36The maximum amount payable is 88 every 12 months, for each denture.3.Denture Repairs/Additions:55301553025540155402Add 1 toothAdd 2 teeth or moreAdd 1 tooth and claspAdd 2 teeth or more and claspBenefit Provisions – HealthDental care - 51616 30.92 30.92 95.16 95.16 30.92 30.92 95.16 95.16C- DC 6
APPENDIX IIBENEFIT PROVISIONS – DCCODE SERVICEFEEGP4.SPECIALISTDenture Relines56211562125622156222Complete upper dentureComplete lower denturePartial upper denturePartial lower denture 126.92 126.92 126.92 126.92 126.92 126.92 126.92 126.92A denture reline is covered once every 36 months.No coverage is provided for a reline provided within 3 months of the date thedenture was inserted.The fees shown include lab fees. For commercial or in-office lab fees shownseparately, the maximum allowable fee is 25.73.Benefit Provisions – HealthDental care 51616C-DC 7
ADULT EMERGENCY DISCRETIONARY DENTAL PLAN - POLICY #51616 Coverage is for Emergency Services only as described on page 3. Benefit Provision Coverage is provided for the services listed in the Ontario Works in Peel Schedule of Emergency Dental/Denture Services and Fees (Appendix I) when they are required as a
