Patrica Rosco

• Claim form (CDA/CLHIA standard, or computer-generated treatment form)

  Matrix Restorative services — Claim form: Yes CDCP supporting documentation requirements for preauthorization submissions (updated 2026-01-26) Restorative services — Claim form: Yes Open the source document
• Treatment plan details — all relevant completed and pending treatment

  Matrix Restorative services — Tx plan: Yes (footnote 1) CDCP supporting documentation requirements for preauthorization submissions (updated 2026-01-26) Restorative services — Tx plan: Yes (footnote 1) Treatment plan details indicating all relevant completed and pending treatment needs ... Does not need to be a stand-alone document labelled 'treatment plan' so long as the information is included in the documentation submitted. Open the source document via structured plan
• Dated periapical radiograph of the requested tooth, within 12 months

  Matrix Restorative services — PA+BW (R&L) <=12mo: Yes CDCP supporting documentation requirements for preauthorization submissions (updated 2026-01-26) Restorative services — PA+BW (R&L) <=12mo: Yes Also: CDCP Dental Benefits Guide (effective 2026-04-01), 6.1.2 Radiograph standards: Intraoral radiographs are considered 'current' for preauthorization purposes if dated within the last 12 months of the preauthorization submission. Open the source document
• Dated bitewing radiographs, right and left, within 12 months

  Matrix Restorative services — PA+BW (R&L) <=12mo: Yes CDCP supporting documentation requirements for preauthorization submissions (updated 2026-01-26) Restorative services — PA+BW (R&L) <=12mo: Yes Open the source document
• Dated complete periodontal chart, within 12 months

  Matrix Restorative services — Complete perio chart <=12mo: Yes, crowns only (footnote 7) CDCP supporting documentation requirements for preauthorization submissions (updated 2026-01-26) Restorative services — Complete perio chart <=12mo: Yes, crowns only (footnote 7) If a complete perio chart is not available, a dated PSR for each sextant plus 6-site periodontal measurements for each tooth requested, within last 12 months, will be considered. Open the source document via complete perio chart
• Client is 18 or older

  Guide 6.3.5 Crowns CDCP Dental Benefits Guide (effective 2026-04-01) 6.3.5 Crowns preauth, 18+ Open the source document
• Requested tooth is an incisor, canine, premolar, first or second molar (third molars by exception)

  Guide 6.3.5 Crowns — tooth eligibility CDCP Dental Benefits Guide (effective 2026-04-01) 6.3.5 Crowns — tooth eligibility incisors, canines, bicuspids, 1st and 2nd molars; third molars only where 1st and 2nd are missing and the 3rd is in occlusion with a prosthetic or natural molar Open the source document via standard tooth
• No CDCP crown on this tooth within the previous 96 months

  Grid Schedule B — 2.0 Restoration, crowns CDCP Dental Benefit Grid — Ontario, General Practitioners and Specialists, 2026 Schedule B — 2.0 Restoration, crowns 1/96mo/tooth Open the source document
• Fewer than 4 crowns for this client within the previous 120 months

  Grid Schedule B — 2.0 Restoration, crowns CDCP Dental Benefit Grid — Ontario, General Practitioners and Specialists, 2026 Schedule B — 2.0 Restoration, crowns 4/120mo/client Open the source document
• All basic treatment for active caries and periodontal disease completed

  Guide 6.3.5 Crowns CDCP Dental Benefits Guide (effective 2026-04-01) 6.3.5 Crowns All basic treatment addressing any existing active biological disease (caries and periodontal) must be completed before submitting requests for crowns. Open the source document

  Awaiting the treating dentist's confirmation of 1 criterion.
• Restorability criteria confirmed by the treating dentist

  Guide 6.3.5 Crowns — restorability CDCP Dental Benefits Guide (effective 2026-04-01) 6.3.5 Crowns — restorability Open the source document

  Awaiting the treating dentist's confirmation of 7 criteria.
• Tooth meets the "extensively restored" definition

  Guide 6.3.5 Crowns — extensively restored CDCP Dental Benefits Guide (effective 2026-04-01) 6.3.5 Crowns — extensively restored Open the source document

  Awaiting the treating dentist's confirmation of 1 criterion.

Not applicable here: Endodontically treated tooth has healed; Laboratory fee codes are valid for the 2026 date of service.