I APPEAL NUMBER PART C - DECISION UNDER APPEAL The decision under appeal is the Ministry of Social Development and Poverty Reduction (the ministry) reconsideration decision dated May 28, 2019 which denied the appellant's request for full coverage of dental services provided on November 23, 2018 and December 13, 2018.
Specifically, the ministry is not authorized by legislation to provide coverage for services that are not set out in the Schedule of Fee Allowances-Dentist, Emergency Dental-Dentist or Crown and Bridgework. The ministry is also not authorized to provide coverage for fees above the rates set out in the schedules
PART D - RELEVANT LEGISLATION Employment and Assistance for Persons with Disabilities Regulation, sections 63,63.1 and 64 Employment and Assistance for Persons with Disabilities Regulation, Schedule C, sections 1, 4, 4.1 and 5
Schedule of Fee Allowances- Dentist, Emergency Dental-Dentist, Crown & Bridgework
I APPEAL NUMBER PART E - SUMMARY OF FACTS The appellant is a Person with Disabilities who has been transitioned to Medical Services Only due to receipt of federal pensions and is eligible for dental supplements under sections 63, 63.1, and 64, and Schedule C, sections 4, 4.1, and 5 of the Employment and Assistance for Persons With Disabilities Regulation.
Summary of Key Dates • March 20, 2019- the appellant contacted the ministry to enquire about dental coverage noting that she had paid $3000 for a root canal, the first part had been completed and the next was scheduled for March 21, 2019. The request for coverage had been processed by the dental office, who had submitted a claim to Pacific Blue Cross (PBC), which was denied. The appellant was instructed to provide a copy of the pre-determination from PBC and an invoice, showing what was covered and was not covered. • March 27/ 19- a district supervisor contacted the appellant to explain further documentation was required. Specifically, an invoice that outlined the dental services provided, amounts paid,s ervices rendered and the amount covered by PBC. • March 28/19- the appellant submitted the following documents: o Pre-determination from PBC dated December 12, 2018- tooth 36 • Fee Code 23321-Tooth Colored Restoration-Dentist fee $156- Ministry Rate 103.63 • Fee Code 33145-Root Canal-Dentist fee $1,950-Ministry Rate 00.00 • Fee Code 39212-Opening through artificial crown-Dentist Fee$100-Ministry Rate 00.00 • Dentist Fee Total-$2,206.00 • Ministry Rate Total $103.63 o Standard Dental Claim Form dated March 27,2019-tooth 36 • Date of service-2018/12/13-Fee Code 32314-Pulpectomy-four canals or more-Dentist's Fee-$975 • Date of service-2018/12/13-Fee Code 39212-opening through crown Dentist's Fee-$100 • Date of service-2019/03/21-Fee Code 33145-root canal, retreatment Dentist's Fee-$975 • Date of service-2019/03/21-Fee Code23321-tooth color-Dentist's Fee-$156 • Total Dentist's Fee 2,206.00 o Standard Dental Claim Form dated March 27,2019- tooth 36 • Date ofservice-2018/11/23-Fee Code 01801-Exam and diagnosis-Dentist's Fee-$120 • Total Dentist's Fee- $120 o Patient Receipt dated March 27, 2019 • December 13, 2018- Previous balance $370, Pulpectomy- Dentist's Fee$975, Open Crown- Dentist's Fee$100. Total $1,075 • March 21, 2019-Root canal- Dentist's Fee$975, Molar Bonded-Dentist's Fee $156. Total $1,131 • April 29/19- The ministry received the appellant's Request for Reconsideration • Mav 28/19-Additional information was submitted by the aooellant to suooort her Request
I APPEAL NUMBER for Reconsideration. The ministry denied the appellant's request. The information before the ministry at the time of reconsideration included the following: • A letter from the appellant's advocate dated May 24, 2019 requesting the appellant be afforded additional coverage under emergency dental supplements if the $1000 limit had been exhausted. As well, if there were any remaining amounts from the applicable 2-year time period in which the procedure was performed, that it be applied in addition to emergency dental supplements. • Patient Receipt dated March 27, 2019. Date- November 23, 2018, Complete Endodontic Exam-$120. • Standard dental claim form dated March 27, 2019, November 23, 2018 code 01801, $120 fee. • Patient Receipt dated March 27, 2019. Date December 13/18- $1075, March 21/19-$1,131. • Standard dental claim form no date, fees for December 13/18 and March 21/19 totalling $2,206 • A Letter from PBC dated December 12/18- Dental Predetermination Summary- Total amount submitted-$2,206.00, approved by plan-$103.63 • A PBC predetermination breakdown of coverage dated December 12, 2018 which notes coverage for: o First Page • Procedure 23321- $103.63 • Procedure 33145-$0.00 • Procedure 39212-$0.00 o Second Page • Procedure 23321-$77.34 • Procedure 32314-$0.00 • Procedure 33145-$573.95 • Procedure39212-$0.00 • Twelve page printout from PBC noting claim details of the appellant from July, 2017-May 08,2019 In the Notice of Appeal the appellant stated: • A number of mistakes have been made by the Reconsideration Officer which are important enough to have determined the outcome (decision made).
In the appellant's Request for Reconsideration , section 3- reason for request, the appellant stated: • A total of $2,326 was paid by the appellant. • Pre-authorization for all procedures was sought from PBC. • Funds that paid for the procedure came from funds saved to pay property taxes and Strata-Insurance. • As a senior with Continued Person Status/Medical only she is now receiving considerably less. • She has absolutely no discretionary income. • Her health is severely challenged with surgeries, working to supplement income is not oossible.
I APPEAL NUMBER • The root canal procedure to deal with persistent infection was absolutely necessary. • The procedure was medically necessary. • Due diligence was practised(pre-authorizations sought). • Payment of taxes and strata insurance are due by June. • Her dental plan allows $1000 over 2 years, much of that amount remained unused at the end of the 2017-2018 cycle. January 2019 marked the start of a new cycle with $1000 available for 2019/2010. Appendix A- Appellant Submission in which the appellant stated: • She has tried to point out to several reconsideration members the mistakes that have been made. • The procedure she went through to address the problems with tooth 36. • Important dates: o November 23/18- consult- paid $120 o December 13/18-first part of procedure- paid $1075.00 o March 21/19- second part of procedure- paid $1131.00 • Blue Cross reimbursed the appellant $651.29 • Monies paid for these procedures were savings for tax and strata insurance. Appendix A- Ministry Submission contained: • A letter noting a mistake of payment that was corrected from $77.34 to $103.63. • Record of claims from the specialist's office in terms of her reconsideration request. Appendix B Appellant Submission which contained Patient receipts from the appellant's dental office without notation from the appellant.
Appendix C Appellant Submission which contains Patient receipts from the appellant's dental office and a blue cross statement with notations by the appellant. • Patient receipts from the appellant's dental office note: o As of May 08, 2019 PBC, has paid $85. 77 therefore the appellant's remaining benefit should be $914.23 o For the 2017-2018 time period the appellant spent $277.67 • Blue Cross web account of the appellant notes, benefit period of Jan 1, 2019-Dec 31, 2020, amount used $763.35
At the hearing, the appellant stated: • Her dental work had to be completed by a specialist. • The dental work was an emergency due to pain and infection which have impacted her future surgeries. • She had requested the specialist seek pre-authorization of all procedures but did not determine herself if the procedures would be covered by PBC. • There are issues with her and the reconsideration officer which are being addressed but that do not necessarily have a direct impact on the panel's role in this appeal. • She feels her 2017-2018 benefits of $1000 paid for the $651.29 which put her account at zero then the reconsideration officer contacted PBC in a vindictive manner to have the funds taken from her 2019-2020 benefit oackaae thus reducina her current dental
I APPEAL NUMBER benefits to $236.65. At the hearing, the appellant's advocate: • Asked if the dental schedule could be flexible to allow payment for the appellant in terms of code 32314. The ministry responded by saying no, they were bound by legislation and the fee schedule must be adhered to. • Asked if code 23321 which was increased from $77.34 to $103 could be raised to the Dentist's fee of $156 the ministry responded that the $77 .34 had been a mistake in calculations which was corrected to $103 which is the ministry rate with an additional 10% for use of a specialist. No additional funding is applicable. • Asked if under emergency procedures, the appellant could obtain additional funding. The ministry explained emergency funding uses the same fees and schedule and is not an extra source of monies for the appellant. • Stated the most important issue in this appeal is the protocol followed by the ministry. There has been miscommunication and a break from appropriate procedures from the Reconsideration Officer involved. The break from appropriate protocol has confused and stressed the appellant and he felt the panel should be aware of this issue.
At the hearing the ministry: • Answered the above questions asked by the appellant's advocate. • Stated benefit funds from one two year term cannot be carried over to the next term. • Stated the Schedule and Fees for dental benefits are legislative and cannot be altered by the ministry.
Admissibility of Additional Information The panel considered the information provided in the three submissions made by the appellant and the one by the ministry. • Submission A from the appellant contains a letter from the appellant explaining why she felt the reconsideration decision was unfair. The panel admitted this additional information as being in support of information and records that were before the ministry at the time of the reconsideration, in accordance with Section 22(4)(b) of the Employment and Assistance Act. • Submission A from the ministry contained a letter explaining a mistake in payment by PBC and PBC claim records of the appellant in terms of the appellant's claim. The panel admitted this additional information as being in support of information and records that were before the ministry at the time of the reconsideration, in accordance with Section 22(4)(b) of the Employment and Assistance Act. • Submission 8 and C from the appellant were to be one submission. The content of the submission contains patient receipts from the appellant's dental office and a blue cross statement with notations by the appellant which notes ·payments and the balances of benefit accounts. The panel admitted this additional information as being in support of information and records that were before the ministry at the time of the reconsideration,
in accordance with Section 22(4)(b) of the Employment and Assistance Act.
I APPEAL NUMBER PART F -REASONS FOR PANEL DECISION The issue under appeal is the ministry's reconsideration decision, dated May 28, 2019 which held that the appellant was not eligible for full coverage of dental services provided on November 23, 2018 and December 13, 2018. The ministry held that it is not authorized by legislation to provide coverage for services that are not set out in the Schedule of Fee Allowances-Dentist, Emergency Dental-Dentist or Crown and Bridgework. The ministry is also not authorized to provide coverage for fees above the rates set out in the schedules.
Relevant Legislation Employment and Assistance for Persons with Disabilities Regulation Dental supplements 63 The minister may provide any health supplement set out in section 4 [dental supplements] of Schedule C to or for (a) a family unit in receipt of disability assistance,
(b) a family unit in receipt of hardship assistance, if the health supplement is provided to or for a person in the family unit who is under 19 years of age, or (c) a family unit, ift he health supplement is provided to or for a person in the family unit who is a continued person. [en. B.C. Reg. 145/2015, Sch. 2, s. 4; am. B.C. Reg. 161/2017, App. 2, s. 2.J Crown and bridgework supplement 63.1 The minister may provide a crown and bridgework supplement under section 4.1 of Schedule C to or for
(a) a family unit in receipt of disability assistance, if the supplement is provided to or for a person in the family unit who is a person with disabilities, or (b) a family unit, if the supplement is provided to or for a person in the family unit who (i) is a continued person, and (ii) was, on the person's continuation date, a person with disabilities. [en. B.C. Reg. 145/2015, Sch. 2, s. 4.] Emergency dental and denture supplement 64 The minister may provide any health supplement set out in section 5 [emergency dental supplements] of Schedule C to or for (a) a family unit in receipt of disability assistance, (b) a family unit in receipt of hardship assistance, or (c) a family unit, if the health supplement is provided to or for a person in the family unit who is a continued person. [en. B.C. Reg. 145/2015, Sch. 2, s. 4.J
Employment and Assistance for Persons with Disabilities Regulation, Schedule C Definitions 1 In this Schedule: "basic dental service" means a dental service that (a) if provided by a dentist, (i) is set out in the Schedule of Fee Allowances- Dentist that is effective September I, 2017 and is published on the website of the ministrv of the minister, and
I APPEAL NUMBER (ii) is provided at the rate set out in that Schedule for the service and the category of person receiving the service, (b) if provided by a denturist, (i) is set out in the Schedule of Fee Allowances -Denturist that is effective September I, 2017 and is published on the website of the ministry of the minister, and (ii) is provided at the rate set out in that Schedule for the service and the category of person receiving the service,
and (c ) if provided by a dental hygienist, (i) is set out in the Schedule of Fee Allowances -Dental Hygienist that is effective September 1, 2017 and is published on the website ofth e ministry ofth e minister, and "dentist" means a dentist registered with the College of Dental Surgeons ofB ritish Columbia continued under the Health Professions Act; "emergency dental service" means a dental service necessary for the immediate relief of pain that, (a) if provided by a dentist, (i) is set out in the Schedule of Fee Allowances -Emergency Dental-Dentist, that is effective September 1, 2017 and is published on the website of the ministry of the minister, and (ii) is provided at the rate set out in that Schedule for the service and the category of the person receiving the
service, and (b) if provided by a denturist, (i) is set out in the Schedule of Fee Allowances -Emergency Dental- Denturist, that is effective September 1, 2017 and is published on the website of the ministry of the minister, and (ii) is provided at the rate set out in that Schedule for the service and the category of the person receiving the service; "specialist" means a medical practitioner recognized as a specialist in a field of medicine or surgery in accordance
with the bylaws made by the board for the College of Physicians and Surgeons of British Columbia under section 19 (I) (k.3) and (k.4) of the Health Professions Act.
Dental supplements 4 (1) In this section, "period" means (a) in respect of a person under 19 years of age, a2 year period beginning on January 1, 2017, and on each subsequent January 1 in an odd numbered year, and (b) in respect of a person not referred to in paragraph (a), a2 year period beginning on January 1,2 003 and on each subsequent January 1 in an odd numbered year. (1.1) The health supplements that may be paid under section 63 [dental supplements] of this regulation are basic
dental services to a maximum of (a) $2 000 each period, if provided to a person under 19 years of age, and (b) $1 000 each period, if provided to a person not referred to in paragraph (a). (c ) Repealed. [B.C. Reg. 163/2005, s. (b) .] (2) Dentures may be provided as a basic dental service only to a person (a) who has never worn dentures, or (b) whose dentures are more than 5 years old. (3) The limits under subsection (1.1) may be exceeded by an amount necessary to provide dentures, taking into
account the amount remaining to the person under those limits at the time the dentures are to be provided, if (a) a person requires a full upper denture, a full lower denture or both because of extractions made in the previous 6 months to relieve pain, (b) a person requires a partial denture to replace at least 3 contiguous missing teeth on the same arch, at least one of which was extracted in the previous 6 months to relieve pain, or (c ) a person who has been a recipient of disability assistance or income assistance for at least 2 years or a dependant of that person requires replacement dentures. (4) Subsection (2) (b) does not apply with respect to a person described in subsection (3) (a)who has previously had a partial denture. (5) The dental suoolements that may be provided to a person described in subsection (3) (b), or to a person
I APPEAL NUMBER described in subsection (3) (c ) who requires a partial denture, are limited to services under (a) fee numbers 52101 to52402 in the Schedule of Fee Allowances -Dentist referred to in paragraph (a) of the defmition "basic dental service" in section 1 oft his Schedule, or (b) fee numbers 41610, 41612, 41620 and 41622 in the Schedule ofFeeA!lowances-Denturist referred to in paragraph (b) of the defmition "basic dental service" in section 1 of this Schedule.
(6) The dental supplements that may be provided to a person described in subsection (3) (c) who requires the replacement of a full upper, a full lower denture or both are limited to services under (a) fee numbers 51101 and 51102 in the Schedule of Fee Allowances-Dentist referred to in paragraph (a) of the defmition "basic dental service" in section I of this Schedule, or (b) fee numbers 31310, 31320 or 31330 in the Schedule of Fee Allowances-Denturistreferred to in paragraph (b) of the definition "basic dental service" in section 1 of this Schedule. (7) A reline or a rebase of dentures may be provided as a basic dental service only to a person who has not had a reline or rebase of dentures for at least 2 years. Crown and bridgework supplement 4.1 (1) ln this section, "crown and bridgework" means a dental service (a) that is provided by a dentist, (b)that is set out in the Schedule of Fee Allowances-Crown and Bridgework, that is effective April I, 2010 and is published on the website of the ministry of the minister, ( c) that is provided at the rate set out for the service in that Schedule, and (d ) for which a person has received the pre-authorization of the minister. (2) A health supplement may be paid under section 63.l of this regulation for crown and bridgework but only if the minister is of the opinion that the person has a dental condition that carmot be corrected through the provision of basic dental services because (a) the dental condition precludes the provision of the restorative services set outu nder the Restorative Services
section of the Schedule of Fee Allowances -Dentist, and (b) one of the following circumstances exists: (i) the dental condition precludes the use of a removable prosthetic; (ii) the person has a physical impairment that makes it impossible for him or her to place a removable prosthetic; (iii) the person has an allergic reaction or other intolerance to the composition or materials used in a removable prosthetic; (iv) the person has a mental condition that makes it impossible for him or her to assume responsibility for a removable prosthetic. (3) The minister must also be satisfied that a health supplement for crown and bridgework will be adequate to correct the dental condition. (4 ) A health supplement for crown and bridgework may not be provided in respect of the same tooth more than once in any period of 60 calendar months. Emergency dental supplements 5 The health supplements that may be paid for under section 64 [emergency dental and denture supplements] of this regulation are emergency dental services. Schedule of Fee Allowances- Dentist, Emergency Dental-Dentist, Crown & Bridgework (related to appeal) Part A - Preamble - Dental Supplements - Dentist
The overall intent of the Ministry of Social Development and Poverty Reduction (Ministry)Dental Supplements is to provide coverage for basic and emergency dental services to eligible individuals who receive assistance through the BC Employment and Assistance(BCEA) Program and children in low income families. The attached Part 8 - Schedule of Fee Allowances - Dentist outlines the eligible services and fees associated with the Ministry's Dental Supplements and the provision of basic dental services. It contains the rules, freauencv and financial limits associated with each service. All frequency
I APPEAL NUMBER limitations include services performed by dentists, denturists and hygienists. The following information provides details on the Ministry's Dental Supplements, how to confirm eligibility and obtain payment for services rendered.
Eligibility for Dental Supplements It is important to note that the Ministry provides varying levels of benefits and some individuals may have coverage for basic dental services with a 2-year limit while others are limited to coverage of emergency dental services only. To ensure active coverage is in place and to confirm the type and amount of coverage available, eligibility must be confirmed for all patients prior to proceeding with any treatment. Procedures for confirming eligibility for your patients are outlined on page (v) under the Eligibility Information section.
BCEAAdults Adults who are eligible for basic dental services under Ministry Dental Supplements are eligible for a $1,000 limit every 2- year period beginning on January 1st of every odd numbered year. The applicable fees for services provided to adult patients are listed in the Schedule of Fee Allowances - Dentist under the column marked "Adult"
Emergency Dental Supplements For Ministry clients who are not eligible for the previously noted 2-year limit or those who have exhausted their limit, some short-term assistance may be available through Emergency Dental Supplements. Children covered under the Healthy Kids program are also eligible for Emergency Dental Supplements. Emergency Dental allows for treatment of an eligible person who needs immediate attention to relieve pain, or to control infection or bleeding or if a person's health or welfare is otherwise immediately jeopardized.
Specific and comprehensive information regarding allowable emergency services along with their associated fees, rules and restrictions and billing information can be found under Part C - Preamble -Emergency Dental Supplements and Part D - Schedule of Fee Allowances - Emergency Dental - Dentist. Emergency services must be billed on a separate claim form and clearly marked as "Emergency".
Crown and Bridge Supplement Specific and comprehensive information regarding allowable services along with their associated fees, rules and restrictions and billing information can be found under Part E - Preamble - Crown and Bridgework Supplement and Part F - Schedule of Fee Allowances - Crown and Bridgework.
Eligibility Information Eligibility must be confirmed for all patients prior to treatment, including those covered by the Emergency Dental Supplement. We recommend you request picture identification in addition to their Personal Health Number (PHN) from new patients.
You must confirm that there are sufficient funds available within your patient's limit to pay for scheduled services and previous dental history should be checked for time-limited procedures. Treatment involving more than one practitioner or a specialist should be coordinated to ensure sufficient funds are available
for all services planned.
I APPEAL NUMBER To ensure that your patient has active Ministry sponsored coverage and to determine the level of this coverage, eligibility must be confirmed immediately prior to providing service, as coverage can change from month to month.
Steps to confirm a patient's eligibility: 1. Obtain the patient's Personal Health Number (PHN) from their Care Card or BC Services Card. 2. Access PROVIDER net at www.providernet.ca to confirm active coverage and look up plan limits available for services, or contact Pacific Blue Cross at: Vancouver: 1-604-419-2780AII other Communities: 1-800-665-1297
If Ministry clients or parents of children covered through the Healthy Kids Program have questions related to their coverage, they should be referred to the Ministry's Dental Information Line at 1-866-866-0800.
Payment Process Claims under the Ministry's Dental Supplements will be paid in accordance with the Schedule of Fee Allowances - Dentist and these fees represent the maximum amount the Ministry can pay for the services billed.
Claim Submission: Dentists can submit claims electronically to Pacific Blue Cross via CDA net for services provided under a patient's Basic Coverage (2-year limit). Some exclusions from CDA net are: 1. Submissions that require explanations on the claim form (e.g.: Emergency claims, General Anaesthetic, Crown and Bridge, etc.) and/or, 2. Submissions that require supporting documentation (e.g.: lab slips, clinical descriptions, radiographs, photographs, etc.)
Claims, including previously noted claims excluded from CDA net process, may also be submitted on a standard dental claim form and sent to: Pacific Blue Cross PO Box 65339Vancouver, BCV5N 5P3
Certified specialists, including oral surgeons may receive an additional 10% on services billed. Refer to page 24 of the Schedule of Fee Allowances - Dental - Dentist
Treatment completed under the Emergency Dental Supplements must be submitted on a separate claim form and will be paid in accordance with the Schedule of Fee Allowances - Emergency Dental - Dentist.
To facilitate payment, it is essential that the submitted claim form be completed as accurately and thoroughly as possible using the patient's name and PHN. Where a claim form is correctly completed and the service provided is an eligible service covered by the Ministry, payment can be expected within 30 days of receipt of the claim. Rebilling within 30 days may not only hold up payment of the original • claim, but will also delay the processing of subsequent claims.
Note: Claims requiring review by a dental consultant may take longer to process. All claims are processed on a "first come, first served" basis therefore timely submission is encouraged. Claims must be submitted within one year of the date of service. No payment will be made on any claim received later than one year from the date of service. If there is an error on your billing, subsequent claims mav ieonardize the oavment of your rebillini:i.
APPEAL NUMBER The dentist must bill the actual service(s) rendered. An alternative fee item number should not be substituted. All claims must be submitted under the payment number of the dentist performing the service(s). Claims, resubmissions and adjustment requests must bear the dentist's signature. This confirms the work was completed and accurately billed. The dentist remains solely responsible for all claims submitted.
Every time a claim is submitted, it indicates the dental practitioners understanding of, and agreement with the terms, conditions and guidelines set out in this fee schedule. The Ministry will not pay for
services rendered by a dental practitioner who is not registered to practice in BC, or provides services outside their scope of practice, or outside of limits and conditions on their practice.
Where payment of a claim has been adjusted or refused, the remittance statement will include an explanation code.
Specialist Referrals Certified specialists, including oral surgeons may receive an additional 10% on services billed from the Schedule of Fee Allowances - Dentist. The Ministry contractor must have a record of the specialty on their billing system and the referring practitioner must be indicated on the claim form. If either of these is missing, the claim will be refused or reduced. If the referring practitioner is a Medical Doctor, please indicate this clearly on the claim form. As fee item 01601 - Examination and Diagnosis, Surgical by Oral Surgeon is restricted for use by Oral Surgeons only the additional 10% will not be applied to this fee
item.
Schedule of Fee Allowances - Dentist Effective September 1, 2017 ROOT CANAL THERAPY Paid once per tooth per lifetime on permanent teeth or retained primary teeth ONLY. Where there is no permanent successor, the dentist must indicate on claim that tooth is a retained primary tooth. To include treatment plan, clinical procedures, with appropriate radiographs, including temporary restoration but excluding final restoration. Post-operative radiographs may be requested to support claims for two canals on permanent cuspid or anterior teeth.
FEE No. FEE DESCRIPTION 33111 One canal 33121 Two canals 33131 Three canals 33141 Four or more canals Apexification (induced apical closure) Note: Paid on permanent teeth only once per tooth per lifetime and to include biomechanical preparation and placement of dentogenic media.
FEE FEE DESCRIPTION No. 33601 Aoexification one canal /first visit
FEE AMOUNT Adult Child 254.17 327.96 330.93 421.46 469.13 600.28 521.77 671.51
FEE AMOUNT Adult Child 83.21 105,36
includina ouloectomv) 33602 Apexification two canals (first visit includinQ pulnectomv) 33603 Apexification three canals (first visit includina ouloectomv)
33604 Apexification four canals (first visit includina ouloectomv)
Note: Re-insertion of dentogenic media will be paid on permanent teeth only to a maximum of three times per tooth per lifetime.
FEE FEE DESCRIPTION No. 33611 Re-Insertion of dentogenic media per visit one canal
33612 Re-Insertion of dentogenic media per visit two canals
33613 Re-Insertion of dentogenic media per visit three canals
33614 Re-Insertion of dentogenic media per visit four canals
Appellant's Position The appellant feels her dental costs should be fully covered as she followed the appropriate protocol, (seeking preauthorization) and had no choice but to have a dental specialist complete the required root canal as her regular dentist was not able to conduct the procedure. She also contends, her condition was an emergency due to the pain and consistent infection and therefore should be able to receive additional payment through the dental emergency legislation.
Ministry's Position The ministry is not authorized to provide funding for services that are not set out in the Schedules of fee Allowances - Dentist, Emergency Dental-Dentist or Crown and Bridges. As well, the ministry is not authorized to provide coverage for fees above the rate set out in the Schedules. Coverage has been provided in accordance with the EAPWD Regulation, sections 63, 63.1, 64 and Schedule C sections 1, 4, 4.1, and 5.
Panel Decision The panel's focus in this appeal must be the decision given in the Reconsideration Decision dated May 28, 2018 where the appellant was denied full funding for dental services provided November 23, 2018 and December 13, 2018. Evidence and testimony shared in terms of where and how funding was handled by the ministry in terms of other dental procedures is beyond the scope of responsibility of the appeal panel. Legislation sets out what the Ministry may pay for and encourages applicants to confirm the rate covered in services before undergoing a procedure. Although the legislation allows for maximum rates over a time period, the Ministry still mav onlv oav for items in the schedule at the orescribed rates. The panel is hopeful
APPEAL NUMBER 117.34 149.14 154.51 197.37
159.66 204.79
FEE AMOUNT Adult Child 27.76 34.80
38.84 49.12
55.52 70.49
62.58 80.14
r APPEAL NUMBER resolution to these outstanding issues can and will be addressed by the ministry and appellant. On November 23, 2018 the appellant was given an Examination and Diagnosis, Endodontic, Complete, Code 01801 and paid $120.00. As the fee code 01801 is not set out in the ministry's Schedule of Fee Allowances- Dentist or Emergency Dental-Dentist the panel finds the ministry's determination the appellant was not eligible for reimbursement was a reasonable application of the relevant legislation.
On December 13, 2018 the appellant was given a Pulpectomy, four canals or more, code fee 32314 and received an Opening Through Artificial Crown-Molars, code 39212 and paid $1075.00. As the fee codes 32314 and 39212 are not set out in the ministry's Schedule of Fee Allowances- Dentist or Emergency Dental-Dentist the panel finds the ministry's determination the appellant was not eligible for reimbursement was a reasonable application of the relevant legislation.
Conclusion The panel finds the ministry's reconsideration decision was reasonably supported by the evidence and confirms the ministry's reconsideration decision. The appellant is not successful in her appeal.
Appellant's Position The appellant feels her dental costs should be fully covered as she followed the appropriate protocol, (seeking preauthorization) and had no choice but to have a dental specialist complete the required root canal as her regular dentist was not able to conduct the procedure. She also contends, her condition was an emergency due to the pain and consistent infection and therefore should be able to receive additional payment through the dental emergency legislation.
Ministry's Position The ministry is not authorized to provide funding for services that are not set out in the Schedules of fee Allowances - Dentist, Emergency Dental-Dentist or Crown and Bridges. As well, the ministry is not authorized to provide coverage for fees above the rate set out in the Schedules. Coverage has been provided in accordance with the EAPWD Regulation, sections 63, 63.1, 64 and Schedule C sections 1, 4, 4.1, and 5.
Panel Decision The panel's focus in this appeal must be the decision given in the Reconsideration Decision dated May 28, 2018 where the appellant was denied full funding for dental services provided November 23, 2018 and December 13, 2018. Evidence and testimony shared in terms of where and how funding was handled by the ministry in terms of other dental procedures is beyond the scope of responsibility of the appeal panel. The panel is hopeful resolution to these outstanding issues can and will be addressed by the ministry and appellant.
On November 23, 2018 the appellant was given an Examination and Diagnosis, Endodontic, Complete, Code 01801 and paid $120.00. As the fee code 01801 is not set out in the ministry's Schedule of Fee Allowances- Dentist or Emen:iencv Dental-Dentist the panel finds the ministrv's
I APPEAL NUMBER determination the appellant was not eligible for reimbursement was a reasonable application of the relevant legislation.
On December 13, 2018 the appellant was given a Pulpectomy, four canals or more, code fee 32314 and received an Opening Through Artificial Crown-Molars, code 39212 and paid $1075.00. As the fee codes 32314 and 39212 are not set out in the ministry's Schedule of Fee Allowances- Dentist or Emergency Dental-Dentist the panel finds the ministry's determination the appellant was not eligible for reimbursement was a reasonable application of the relevant
legislation.
Conclusion The panel finds the ministry's reconsideration decision was reasonably supported by the evidence and confirms the ministry's reconsideration decision. The appellant is not successful in
her appeal.
I APPEAL NUMBER PART G -ORDER THE PANEL DECISION IS: (Check one) 12sJUNANIMOUS □BY MAJORITY THE PANEL 12sJCONFIRMS THE MINISTRY DECISION □RESCINDS THE MINISTRY DECISION If the ministry decision is rescinded, is the panel decision referred back to the Minister for a decision as to amount? □Yes □No LEGISLATNE AUTHORITY FOR THE DECISION: Employment and Assistance Act Section 24(1}(a) D or Section 24(1)(b) l2sl and Section 24(2)(a) [gj or Section 24(2)(b) D PART H -SIGNATURES PRINT NAME Charles Schellinck
SIGNATURE OF CHAIR DATE(YEAR/MONTH/DAY} 2019/07/20
PRINT NAME Inge Morrissey
SIGNAlURE OF MEMBER DATE(YEAR/MONTH/DAY} . 2019/07/20 PRINTNAME Carman Thompson
SIGNATURE OF MEMBER DATE(YEAR/MONTH/DAY) 2019/07/20