Dental Fee Guide
A dental fee guide is a provincially issued schedule that lists the standard or recommended prices for dental procedures. Each province and territory in Canada publishes its own guide annually, outlining suggested fees for everything from cleanings and fillings to crowns and dentures.
How It Works
A dental fee guide is a schedule published by a Canadian province or territory's dental association that lists suggested or recommended prices for dental procedures, assigning a price to each of the more than 1,000 procedure codes dentists use to describe and bill for their services. Most guides are released at the beginning of each year. These fees are suggestions only, so dentists are not required to follow them when setting their own prices. Insurers, however, use the guide as a benchmark to set their Reasonable and Customary (R&C) amounts, which determine how much a plan will reimburse for a given procedure regardless of what the dentist actually charges. When a plan covers a stated percentage of dental costs, that percentage is typically applied to the fee-guide amount rather than the dentist's actual charge. If a dentist charges more than the guide, and therefore more than the insurer's R&C amount, the plan member is responsible for paying the difference out of pocket. The Canadian Dental Care Plan likewise bases its covered services on national references including the Canadian Dental Association Uniform System of Coding and List of Services and the Quebec dental association (ACDQ) fee guide.
Example:
Suppose an Ontario plan member with 80 percent routine dental coverage visits a dentist whose fee for a procedure is higher than the amount listed in the provincial dental fee guide. Because the insurer reimburses 80 percent of the fee-guide amount rather than 80 percent of the dentist's actual charge, the member pays both their normal coinsurance share and the full gap between the dentist's fee and the guide amount. Asking the dentist to submit a predetermination beforehand would have shown exactly what the plan covers and what would be left to pay out of pocket.
What to Watch For:
Remember that fee-guide prices are suggestions only, so a dentist's charge can sit above the guide and above the insurer's R&C amount, leaving you responsible for the difference. Because the plan applies your coverage percentage to the fee-guide amount rather than the dentist's actual charge, that gap is yours to cover. Requesting a predetermination, where the dentist submits the planned procedures to the insurer before treatment, lets you confirm how much your plan will pay according to the applicable fee schedule before any work is done.
