Information for Dental and Other Health Professionals and Educators

York Region’s Oral Health Summary Reports show that tooth decay trends in York Region children have stayed the same since 2011. Each year, about 50,000 children are screened by York Region Public Health Dental Program staff in York Region elementary schools and at Public Health dental clinics. Between 2011 and 2014, approximately 30 per cent of school-aged children had dental caries.

The Canadian Dental Association recommends the assessment of infants by a dentist within six months of the eruption of the first tooth or by one year of age. The Canadian Paediatric Society directs parents to take their child for a first dental visit by 12 months to establish a dental home and regular, preventive care.

Early childhood caries (ECC)

Early childhood caries (ECC) is defined as the presence of one or more decayed, missing or filled tooth surfaces in the primary teeth of preschool children. The American Academy of Pediatric Dentistry states that “in children younger than three years of age, any sign of smooth surface caries is indicative of severe ECC.”

Poor oral health in children can lead to:

• Pain
• Difficulty eating
• Difficulty sleeping
• Speech problems
• Poor overall health
• Higher risk of tooth decay in adult teeth

Dental problems in early childhood have been shown to impact general growth and cognitive development and lead to poor self-esteem, poor school behaviour and poor employability in the future. ECC is preventable by maintaining good oral health from an early age by establishing habits such as brushing teeth twice daily, following a healthy diet and keeping regular preventive appointments.

Early childhood caries (ECC) treatment and prevention

Treating ECC in hospitals under general anesthetic accounted for 31 per cent of all day surgery for children from one to five years of age.This is the leading cause of day surgery for children in this age group. The cost of hospital care for this surgery in Canada is $21.2 million per year. Babies who have their first dental visit by their first birthday are more likely to have regular preventive services and better oral health outcomes as a result.

Health care professionals can help play a role in preventing ECC in young children by recommending parents take their children to a dentist by their first birthday. Evidence increasingly suggests that preventive interventions within the first year of life are critical to help prevent ECC. At the first dental visit, the dental professional will:

• Provide a thorough oral exam
• Complete a caries risk assessment
• Instruct parents on proper oral hygiene practices for their children
• Discuss dietary habits related to good oral health
• Provide anticipatory guidance
• Apply fluoride varnish if the child is at-risk for caries

First Visit, First Tooth, a course offered through the Canadian Dental Association, can help inform dental professionals about the importance of providing the first dental visit by one year of age and provides tips on how to effectively examine infants and toddlers.

The York Region Public Health Dental Program has developed Tips for a first dental visit examination, a tool with a checklist to help guide dental professionals in performing the first dental visit exams. In addition, this Snack tool was created to assist in discussing dietary habits, such as which snacks to choose more/less often.

The Ontario Dental Association (ODA) has developed a fee code for dentists for the first dental visit/orientation for children under three years of age. The code is 01011 and can be found on page five of the Diagnostic Services of the ODA fee guide. This code is also part of the Healthy Smiles Ontario fee schedule for dental providers. For dental hygienists, the first dental hygiene visit/orientation fee code is 00131 and is found in the Ontario Dental Hygienists Association (ODHA) and HSO fee guides.

Additional resources are available in Dental Health Resources

As of January 1, 2016, the following six publicly funded dental programs have been combined into the new HSO program:

• Dental benefits for children under Ontario Works (OW)
• Dental benefits for children under the Ontario Disability Support Program (ODSP)
• Dental benefits for children under the Assistance for Children with Severe Disabilities (ACSD)
• Healthy Smiles Ontario (HSO)
• Children in Need of Treatment (CINOT)
• Preventive oral health services provided by local public health units

The HSO program covers urgent and regular visits to a licensed dental care provider to maintain good oral health for children 17 years old and under. Clients who are covered under HSO will have an HSO client card. Make sure that the card has not expired before starting treatment. Providers can phone Accerta directly at 416-363-3377 or 1-877-258-2658 to determine if a child is enrolled in the program.

January 2019 Amendments to Healthy Smiles Ontario Schedule of Dental Services and Fees

HSO Schedule of Fees and Services for Dentist Providers

HSO Schedule of Fees and Services for Non-Dentist Providers

Further operational guidance for participating dental providers is included in the Healthy Smiles Ontario Operational Guide for Dental Providers.

Private dental providers:

Enrolling clients in HSO

Non-emergency/regular business hours

Private dental providers can refer clients to the York Region Public Health Dental Program for help to access the Emergency and Essential Services Stream (EESS) stream of the HSO program or they can help them to enroll in the HSO-EESS stream using the Emergency and Essential Services Stream (EESS) Form

Emergency/regular business hours

Private dental offices can enroll emergency clients who are unable to pay for dental treatment due to financial hardship in HSO-EESS

• Use the Emergency and Essential Services Stream (EESS) Form for dental providers
• Fax completed form to Accerta
  Accerta will send a response including the client’s assigned HSO number
• Submit claims for emergency services performed during the visit using the client’s assigned HSO number

Emergency/after-hours - outside of Accerta’s contact centre business hours (Monday to Friday, 8 a.m. to 8 p.m.)

When Accerta is closed, dental offices can be reimbursed for treatment that is for relief of pain, prior to the client being enrolled in HSO.

• To receive payment for the emergency appointment, submit the completed and signed Emergency and Essential Services Stream (EESS) Form to Accerta
• Accerta will send a response, including the client’s assigned HSO number, on the next business day
• Submit claims for emergency services performed during the visit using the client’s assigned HSO number

Providers assessing clinical eligibility for EESS will be reimbursed for an emergency or specific examination whether the child is ultimately deemed eligible or not.

For all other appointment bookings for future treatment, dental offices will require the client’s assigned HSO number.

Additional Coverage through Dental Special Care Plan

• The Dental Special Care Plan (DSCP) is limited to Ontario Disability Support Program (ODSP) and Assistance for Children with Severe Disabilities (ACSD) clients
• Dental offices can apply for additional coverage for those HSO clients who disclose they are recipients of ODSP or ACSD and who require additional treatment beyond the HSO Schedule of Fees.  The application is done by completing and faxing a standard pre-treatment form to Accerta requesting “Dental Special Care Plan” with rationale. Here are some examples for of possible rationale:
  • Medical and/or psychosocial condition
  • Prescribed medication or medical treatment impacts their oral health and/or dental treatment
  • Current oral health impacts their medical and/or psychosocial condition and/or their medical treatment

Dental Special Care Plan - Length of Coverage

• Clients approved for the DSCP will have access to additional services for up to five years or their 18th birthday to help manage their risk for disease
• During this time period when a client is enrolled onto the DSCP, providers will not have to re-submit pre-authorization requests for each service under the DSCP, except for crowns
• For crowns only, providers must identify or list the pre-authorization criteria using a pre-authorization request

Improvements to HSO billing processes

Providers are no longer required to:

• Submit laboratory invoices with their claim for services with laboratory fees (i.e. crowns)
• Submit criteria on the claim form for fluoride
• Submit radiographs, charting or treatment plans with claims

Other helpful information for HSO dental providers

• All HSO cards have an expiry date; please check the date on the card to confirm active coverage prior to providing any services
• HSO clients have the option of using their private dental insurance coverage as well as enrolling in HSO, with HSO as the second payer
• If a client declares they cannot afford to access their private insurance, HSO will be billed exclusively

Multilingual HSO Factsheets

Submitting a Claim

In order to be reimbursed for services provided under HSO, you must submit a claim to Accerta.
Claims may be mailed, sent via secure fax, or submitted electronically (EDI).

Mail:
AccertaClaim Servicorp Inc.
Healthy Smiles Ontario Contact Centre
Station P, P.O. Box 2286
Toronto, ON M5S 3J8

Secure Fax:
416-354-2354 or toll-free at 1-877-258-3392
Accerta Carrier Code is 311140 and can be added under the Instream Network.

Electronic (EDI):
Primary Policy/Plan Number is HSO.

Ontario Works clients over the age of 17 are provided with dental coverage for themselves and the members of their families who are over the age of 17. Please see the York Region Ontario Works Adult Dental Program Handbook for more information.

Verifying Eligibility for Dental Services

To receive benefits, the client must provide a piece of government identification (e.g., health card, driver’s license, etc.). If the client does not have government identification, they can present an Ontario Works statement of assistance.

Effective October 1, 2024, the dental office is responsible for confirming eligibility for Ontario Works clients by using the Eligibility Verification Portal via AccertaWorX at https://accertaworx.accerta.ca. Providers must register for an account with AccertaWorX to access the eligibility verification tool.

Once the client has provided their identification, providers can use this information to verify dental coverage on AccertaWorX.

To verify eligibility, the dental office must:

1. Select YOR as the Group/Policy code
2. Enter the client’s name and date of birth (DOB) or Ontario Works Member ID and date of birth (DOB)

If the client is eligible, the response from the portal will be “Client is eligible”.

If the client is ineligible, please follow the steps provided in the York Region Ontario Works Adult Dental Program Handbook under the section Issues with Verifying Eligibility and Submitting Claims.

For issues with accessing the portal, please contact Accerta at 1-800-505-7430.

ODSP Dependent Adults and Non-Social Assistance Recipients require an eligibility letter to receive dental services. Please have the client contact York Region Access York at 1-877-464-9675. If the client is eligible, an eligibility letter will be sent to the dental office. This letter must be received prior to starting treatment.

Denture Services

Denture offices must obtain an authorization number from York Region Access York (1-877-464-9675) prior to providing denture treatment for Ontario Works adults.

Ontario Works may also provide assistance for dentures to eligible ODSP clients and non-Social Assistance Recipients.

Please have the client contact York Region Access York at 1-877-464-9675 to complete a request for dentures. If the client is eligible, an eligibility letter will be sent to the dental office. This letter must be received prior to starting treatment.

Requests for replacement of dentures within five years require pre-determination and approval before treatment can be provided. Please complete the OW Replacement of Denture Form for these requests.

Service Restrictions

The York Region Ontario Works Adult Dental Program Handbook applies to all adult dental and denture requests through the York Region Ontario Works Dental Program.

Services listed in the Ministry of Children, Community and Social Services (MCCSS) schedule that are limited (coverage provided only for particular tooth numbers) or not covered under the York Region Ontario Works Dental Program are identified in the handbook on page 4 and Appendix 1 and include:

• Polishing (11107) is not covered
• Plastic resin restoration (2321 - 23215 and 23221 - 23225 and 23311 - 23315 and 23321 - 23325) in permanent molars and premolars (14, 15, 16, 17, 18, 24, 25, 26,27, 28, 34, 35, 36, 37, 38, 44, 45, 46,47,48) will only be provided at the cost of silver amalgams
• Posterior endodontic treatment (33131 and 33141) is only approved for anterior teeth and premolar teeth (11, 12, 13, 14, 15, 21, 22, 23, 24, 25, 31, 32, 33, 34, 35, 41, 42, 43, 44, 45)
• Anaesthesia services (General Anaesthetics, Deep Sedation or IV Sedation) (92212 - 92218 and 92222 - 92228 and 92302 - 92308 and 92441 - 92448) are not covered
• Only four units of scaling are covered. Additional units of scaling are not covered

Pre-determination for services outside of the MCCSS Schedule of Dental Services and Fees is not available.

Submitting a Claim

To receive reimbursement for services covered under Ontario Works, you must provide:

• A completed Ontario Works Dental Claim Form with signatures of the dental practitioner and patient
• A copy of the letter of eligibility for ODSP dependent adults or non-Social Assistance Recipients for dental services to confirm the client is eligible for treatment, where appropriate
• For denture services, an authorization number documented on the claim form for Ontario Works clients or a copy of the letter of eligibility for ODSP clients and non-Social Assistance Recipients

Incomplete claims will be returned.

Accerta accepts Electronic Data Interchange (EDI) for dental claims through AccertaWorX. To submit EDI claims, please follow the process outlined in the York Region Ontario Works Adult Dental Program Handbook.

Dental claims can also be mailed to:

Accerta Claims
Station “P”, P.O. Box 310
Toronto, ON M5S 2S8

For services completed prior to August 15, 2016:

Dental claims must be sent to:

The Regional Municipality of York
Community and Health Services Department
Integrated Business Services Branch
Accounting Clerk-Intermediate
17150 Yonge Street, 6th Floor
Newmarket, ON L3Y 8V3