Half of requests for complex dental work are being rejected under national insurance plan

Yahoo

3 days ago

As federal dental care expands to cover most uninsured Canadians, providers say some procedures are being bogged down by paperwork and processing delays.
Health Canada says 52 per cent of requests for pre-authorized dental work between November 2024 and June 2025 have been rejected.
While the vast majority of claims don't need pre-authorization, it's required for more complex and often more expensive procedures, like crowns or partial dentures. Clinics must submit extra documentation like X-rays and dental charts to show the work is medically necessary before it can be covered and completed.
"There's been a lot of confusion for dentists who send in what we would normally send in to a private plan, and it comes back rejected," said Dr. Bruce Ward, a Vancouver dentist and president of the Canadian Dental Association.
"It's a much, much, much higher rejection rate than private plans."
The multibillion-dollar Canadian Dental Care Plan helps cover the cost of dental work for Canadian residents with a family income below $90,000 who don't have access to private insurance. The program fully expanded to cover people aged 18 to 64 last month.
Health Canada says 5.2 million people have been approved for coverage so far, but only about half — 2.2 million — have received care.
And some new patients are getting an unexpected bill, while certain parts of the country are struggling to keep up with a huge influx of appointments, Ward said.
Still, providers told CBC News the program is providing Canadians much-needed access to care — and that issues with the program are improving.
Clinics submit the pre-authorizations through Sun Life, the insurance provider that the federal government contracted to run the program.
Dental offices are sometimes waiting weeks or months for a response, only to be told Sun Life needs additional documentation — further slowing down the process, Ward said.
"A lot of people have been waiting for crowns to be pre-authorized," Ward said. "There was an avalanche of approvals that got sent in."
Health Canada said rejections and delays in pre-authorizations are caused by several factors, including an unexpected high volume of submissions that were missing information.
Oral health-care providers also tell CBC News there were many technical issues with the submission software that have since been largely resolved.
Health Canada has worked to streamline the process and educate providers about how to complete the applications, a spokesperson said.
Eighty per cent of the pre-authorizations are now being processed within seven business days. And more than 90 per cent of the claims, like basic cleanings or fillings, don't require pre-authorization.
But Donna Wells, manager of professional practice at the Canadian Dental Hygienists Association, said the program needs to better cover preventive care.
The plan currently allots one hour of scaling per year for adults. Teenagers get just 15 minutes of scaling.
"These are patients who have not had oral health care, in some cases, for a number of years, because it's been such a financial barrier for them," Wells said.
She said pre-authorization applications for additional scaling are being rejected en masse.
Health Canada says over a million Canadians signed on to the program when it expanded in June, and 94,980 of them received dental care.
But that influx of patients has led to a backlog in some parts of the country, like Atlantic Canada."This program is wonderful, but it's putting a strain on providers," said Natalie Marsh, a dental assistant in North Sydney, N.S., and vice-president of the Canadian Dental Assistants Association.
She said her clinic is already booking appointments for spring 2026.
"You're seeing people who haven't seen a dentist in a long time. So they're coming in with a lot of work to be done," she said.
Providers said patients continue to be under the impression their dental work will be free of charge. But the program reimburses clinics at a rate lower than provincial fee guides, which they often use to set their rates.
That means dental offices can "balance bill," charging the difference between the price of the procedure and what Ottawa will pay them.
"I just had somebody in my office a couple of weeks ago who was very upset, because they'd been told that they were covered 100 per cent," Ward said.
Ward said patients, including seniors, should remember they need to reapply every year.
Despite those challenges, Ward said overall he's found the dental care plan to be "very good" to work with. That sentiment is echoed by other oral health associations.
"It's been a huge boon to a lot of people who frankly would never have been able to afford to have their mouths taken care of," Ward said.
"It's remarkable," he said. "And yes, there's going to be some growing pains."