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Health Benefits Card Coverage

Published Date: August 01, 2011
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03 Dental and Denturist Benefits

ISTHB Regulation, Section 73(2)(d) establishes authority for coverage of services provided by dental professionals (dentists, denturists and dental hygienists) in accordance with agreements with the Alberta Dental Association and College, the College of Alberta Denturists and the College of Registered Dental Hygienists of Alberta.

Workers are not expected to know the detailed list of services in the agreements, as interpretation requires specialized knowledge of dental procedures. The Dentist, Denturist and Dental Hygienist Agreements can be accessed on the Community and Social Services intranet.

INTENT

To provide dental care for eligible adults and children to ensure their dental health and well-being.

POLICY

Eligible adults receiving Income Support (IS), Learner Income Support, and the Alberta Adult Health Benefit (AAHB) are covered for procedures to alleviate pain and infection, and for some diagnostic and preventative procedures. Eligible children in IS and AAHB households and children enrolled in the Alberta Child Health Benefit (ACHB) program are covered for these procedures and some additional procedures. (Children of Learners are enrolled in the ACHB program.)

Responsibility of Vendor

Dental professionals provide services to Community and Social Services clients in accordance with terms of the agreements, which include obtaining pre-authorization from the Alberta Dental Service Corporation (ADSC) for most dental procedures identified in the agreements. Schedules in the agreements list in detail services covered adults and children. ADSC administers the agreements on behalf of Community and Social Services.

The dental professional checks the recipient’s identity and has them sign the pre-authorization and/or claim form.

The dental professional sends the pre-authorization to ADSC listing all of the required dental work. ADSC advises the dental office which procedures are approved or denied based on the client’s coverage as detailed in the dental schedules.

If the procedures are approved, the dental professional can go ahead with the dental work. If the procedures are denied, the dental professional can appeal to the ADSC Review Committee by submitting a letter that lists the required procedures and provides a strong medical rationale, along with a copy of the denied pre-authorization.

Dental professionals send their pre-authorizations, ADSC Review Committee requests and claim forms to:

Alberta Dental Services Corporation
Suite 200, Quik Card Centre
17010 – 103 Avenue
Edmonton, AB T5S 1K7
Fax: 780-426-7581

If the recipient or a household unit member is covered under another primary dental plan (e.g., employer’s dental plan, spouse’s dental plan), the dental professional bills the primary plan first before submitting any remaining portion to ADSC for reimbursement.

Appeal and Health Benefits Exception Committee

Decisions regarding dental and denturist services provided as a Community and Social Services health benefit are defined in Regulations as decisions of the Minister, and therefore, an appeal panel does not have authority to overturn a decision regarding health benefits provided under Part 2 Division 2 of the IESA, or under ISTHB Regulation, Section 73.

If the ADSC Exception Committee denies a benefit, the client may request a review and authorization of the dental or denturist good or service by the Health Benefits Exception Committee (HBEC).

Payment for Services

Alberta Dental Service Corporation (ADSC) administers, adjudicates claims, and pays dental professionals for services provided within the province of Alberta to all IS recipients (including provincially funded Learners) with active files at the time the services were authorized, and all recipients of the ACHB and the AAHB programs.

The recipient presents their health benefits card, or an EMP 0018 Purchase Authorization and Invoice to obtain service.

Replacement of Dentures and Repayment Agreements

Within the Dental and Denturist Agreements, clients with HBC coverage are allowed:

  • One complete or partial denture per arch every 5 years, and
  • One complete or partial denture replacement upon pre-authorization from ADSC when a denture is broken beyond repair or is irretrievably lost.


If the client has an additional request for complete or partial denture replacement within the 5 year period and warranty coverage is not applicable, then

  • The Health Benefits Exception Committee can hear the request in cases where the dentures were lost through no fault of the client (e.g. fire, theft, physical attack by another party), or
  • The supervisor may authorize replacement dentures by Repayment Agreement in cases of neglect or abuse, and where


PROCEDURE

An EMP 0018 Purchase Authorization and Invoice is issued for dental or denturist services for the following circumstances only:

  • If a Health Benefits Card has not yet been issued or a dependant was added to the file after the card was issued and the service is urgently required before the next card is received.
  • For One-Time Issue recipients (client sub-type 81 and 82).


The EMP 0018 Purchase Authorization and Invoice:

  • Is issued to the dental professional
  • Is forwarded by the dental professional to the Alberta Dental Services Corporation for payment,
  • Has no dollar amount,
  • Is used only for services covered in the Agreements, or approved by the Health Benefits Exception Committee.


Service Description for Dentist and Denturist Services

The appropriate Goods Code, Need Code and Description (with the description Standard Dental coverage) for the service must be included on the EMP 0018 Purchase Authorization and Invoice. The services of dental hygienists are included under the code for Standard Dental Services. The period in the description must be the same as the claim form and as the Period of Assistance on the EMP 0018 Purchase Authorization and Invoice, and must cover the dates of service on the vendor’s claim form.