CDCP Claims Rules: Deadlines, Billing and Audits

To get paid correctly by the Canadian Dental Care Plan, a clinic must confirm the patient’s coverage before treatment, bill Sun Life directly within 12 months of the date of service, and keep records that support every claim. Patients cannot claim reimbursement themselves, and any claim can be reviewed after payment. Clinics that build these three habits into the front desk avoid most rejections and recoveries.

Key facts

Who can claim: dentists, denturists, independent dental hygienists, dental specialists, and dental schools and educational institutions for oral health professions.
Deadline: claims must reach the CDCP within 12 months of the date of service, including resubmissions after a rejection.
Who bills: the provider. Patients cannot submit CDCP claims or be reimbursed for out-of-pocket payments.
Payment: by electronic fund transfer or cheque.
Rules source: the CDCP Dental Benefits Guide and Sun Life’s CDCP Claims Processing and Payment Terms.

How clinics bill the CDCP

At launch in 2024, clinics were expected to sign a contract with the plan. In July 2024 the federal government changed course, as CBC News reported, and allowed providers to bill Sun Life claim by claim without formally enrolling. Participation climbed quickly afterwards, and the Canadian Dental Association’s latest assessment says more than 90 per cent of dentists are now taking part.

Whatever the route, the Dental Benefits Guide puts three duties on the provider. Confirm the client’s coverage before treatment. Follow the plan’s rules, including frequency limits and preauthorization requirements. Submit claims in line with the Claims Processing and Payment Terms. Every claim is subject to verification after it is paid.

A claim workflow that works

Verify coverage on the day of the visit. Use an EDI estimate, the CDCP Coverage Look-up tool in Sun Life Direct, or the Sun Life CDCP Contact Centre at 1-888-888-8110. Eligibility can change within a benefit period. In October 2025, Health Canada said an income-calculation error had affected some members and told providers to validate coverage at each visit.
Check the procedure code. Confirm it is covered, check its frequency limit and see whether it needs preauthorization in the current Dental Benefit Grids.
Treat and document. Chart what was done, and keep the radiographs, notes and forms that support it. A procedure code in the record is not enough on its own to substantiate a claim.
Submit directly to Sun Life. Electronic and paper claims are both accepted, and EDI is faster.
Handle other coverage. If the patient has another plan, send the detailed statement or Explanation of Benefits from that plan with the claim.
Reconcile payment. Match EFT deposits or cheques to the claims you submitted and follow up on rejections within days, not months.

The 12-month rule

The deadline is strict. Under the Dental Benefits Guide, a claim must be received within 12 months of the date of service, and claims older than that are not accepted for processing. The same window covers every resubmission after a rejection, such as a missing data element, a wrong procedure code or alternative coverage the patient did not mention. It also covers coordination of benefits with other plans.

That makes unresolved rejections a financial risk. A claim rejected in month 11 and fixed in month 13 is lost. Set a recurring weekly task to review rejected and pending CDCP claims, and flag anything older than six months.

Frequency limits to know by heart

Frequency limits run on rolling periods, not calendar years. If a recall examination is rendered on April 1, 2025, the next one is eligible on April 2, 2026. Some of the limits front desks see most often under the 2026 guide:

Service	Limit
Examinations	Up to 3 in any 12 months in total; recall exam 1 in 12 months
Complete oral examination	1 in any 60 months
Intraoral radiographs (1 to 8 images)	8 in any 12 months
Intraoral complete series (12 to 16 images)	1 in any 60 months
Panoramic radiograph	1 in any 60 months, up to 3 per lifetime
Polishing	Half a unit in any 12 months
Topical fluoride, age 17 and over	1 treatment in any 12 months
Scaling and root planing, age 17 and over	4 units in any 12 months combined
Restorations	Once per tooth surface in any 24 months

For anything beyond these limits, the plan may consider coverage through preauthorization for certain services. Always confirm the current limit in the grids before telling a patient what is covered.

Co-payments and the patient conversation

The CDCP is not full coverage for everyone. According to the Government of Canada, the plan covers 100 per cent of eligible costs at CDCP fees for adjusted family net income under $70,000, 60 per cent from $70,000 to $79,999, and 40 per cent from $80,000 to $89,999. Patients pay the rest as a co-payment directly to the provider.

There is a second gap. The plan pays only at its established fees. If your fee is higher, or the patient chooses services the plan does not cover, the patient may owe the difference. The Canadian Dental Association says that gap is a main reason 37 per cent of CDCP patients still report financial barriers, and that 59 per cent expected care to be completely free, according to CTV News.

The Dental Benefits Guide also encourages providers to avoid charging CDCP clients for costs the plan covers. Practical steps follow from that:

Give a written estimate that separates the CDCP portion from the patient’s portion before treatment.
Explain the co-payment tier in plain words, since each patient’s tier is set by income.
Put the policy for non-covered services in writing and sign it at the first visit.
Check your provincial regulator’s expectations on fee disclosure and billing.

Special cases: lab fees and non-inserted work

Laboratory fees are considered only alongside an eligible procedure, and the plan pays reasonable and customary amounts. It can ask for the lab invoice and adjust the amount.

If a crown is completed but never inserted for reasons outside your control, the CDCP may pay up to 20 per cent of its professional fee plus a reasonable lab fee. For standard dentures the figure is up to 50 per cent. Both require substantial efforts to reach the patient and a written explanation to Sun Life. Claiming without meeting those conditions can lead to recovery of the payment.

Preparing for claim verification

Every CDCP claim can be checked after payment. The guide describes a claims verification program whose aims include detecting administrative errors, recovering overpayments, confirming that clinics kept the documentation their regulator and the plan require, and ensuring treatment was actually received. It also checks that providers are in good standing with their regulatory bodies. A provider found to have intentionally submitted false or incomplete information can lose the right to claim in future.

A clinic that is ready for verification can produce, for any claim:

the dated clinical record and treatment notes;
radiographs and charting that match the procedure code;
the signed estimate or consent;
the Explanation of Benefits from any other plan; and
proof of the date the claim was submitted.

By providing care to CDCP clients, you agree to co-operate with these checks, so build a retrieval routine now.

Common mistakes

Relying on last year’s grid after the April 2026 update.
Treating coverage checked at booking as valid on the treatment date.
Forgetting to send the other plan’s Explanation of Benefits.
Letting a rejected claim sit past the 12-month window.
Billing the patient for amounts the plan covers.

FAQ

Can patients submit their own CDCP claims?

No. Only the provider can claim, and there is no reimbursement for amounts patients pay out of pocket for covered services.

How long do we have to submit a CDCP claim?

Twelve months from the date of service. The same limit applies to any resubmission after a rejection.

Does the CDCP pay our usual fee?

It pays at its own established fees. Patients may owe the difference if your fee is higher, as well as any co-payment based on their income tier.

What happens if a claim is audited?

Sun Life reviews it against your records. Unsupported claims can be recovered, and intentional false submissions can end your eligibility to claim.

Who do we call about coverage?

The Sun Life CDCP Contact Centre is at 1-888-888-8110, and coverage can also be checked in Sun Life Direct or through an EDI estimate.

Sources and update date

Sources: the CDCP Dental Benefits Guide (effective April 1, 2026), the Government of Canada coverage page, a Health Canada statement of October 21, 2025, CBC News and CTV News. Last updated: October 7, 2026. Confirm all limits in the current Dental Benefit Grids.

Next step: add the 12-month review task and the coverage check to your front-desk checklist this week.