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Karen Jones

Send by Oct 22

Crown on #46, lower right first molar · Crown appointment Thursday Oct 29

  1. Needs the patient
  2. Paperwork You
  3. Dentist review Dr. Terry Ackerman
  4. Ready to send You
  5. With Sun Life Sun Life
  6. Decision back You

Fix the paperwork

You

The chart changed after Ophi last compared it with past decisions on Sep 27, 2026, so no denial risk is shown.

  • Add the client's CDCP identifier and date of birth to the patient record in the PMS

    Why
    • CDCP client ID not on the patient record
    • the claim form cannot be completed. The claim form carries the client's CDCP number and date of birth. Ophi reads both from the patient record and cannot derive them from the chart. The number is on the client's CDCP letter and belongs on the patient's CDCP coverage (a Sun Life plan numbered 333333)
    • enter it in the PMS, since the claim is sent from there, then check the chart again.

    Required by 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

Dr. Terry Ackerman can confirm the clinical criteria now, in parallel.

Check the chart again
CDCP requirements8 of 12 documented
  • Awaiting dentist
    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
    CDCP client ID not on the patient record; the claim form cannot be completed
  • Satisfied
    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
  • Satisfied
    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
  • Satisfied
    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
  • Satisfied
    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
  • Satisfied
    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
  • Satisfied
    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
  • Satisfied
    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
  • Satisfied
    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
  • Awaiting dentist
    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.
  • Awaiting dentist
    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.
  • Awaiting dentist
    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.

What Ophi read in the chart4 radiographs, 3 perio records, 4 notes

Radiographs

PANO
Jun 27, 2003
PA #46
Aug 20, 2026, current until Aug 20, 2027
BW right #14, #15, #16, #17, #44, #45, #46, #47
Aug 20, 2026, current until Aug 20, 2027
A bitewing does not show the root tip.
BW left #24, #25, #26, #27, #34, #35, #36, #37
Aug 20, 2026, current until Aug 20, 2027

Periodontal charting

Perio chart Jun 27, 2003 uncertified draft
6 sites per tooth, 28 of 28 teeth
Perio chart Jun 27, 2003 uncertified draft
6 sites per tooth, 28 of 28 teeth
Perio chart Aug 20, 2026
6 sites per tooth, 28 of 28 teeth, current until Aug 20, 2027
#46 323323

Clinical notes

Jun 11, 2004, Dr. Terry Ackerman

[Date]23/Jun/2003 [Type]Restoration [Desc]Existing Condition [Tooth]37 [Surf]O [Mat]ME [Pvdr]T 37 MESIAL ROOT BUCCAL GUM HAS AMALGAM TATOO

Jun 11, 2004, Dr. Terry Ackerman

[Date]23/Jun/2003[Type]Restoration [Desc]Existing Condition [Tooth]46 [Surf]DOMLB [Mat]PL [Pvdr]T 46 feels good no symptoms. hyg. appt booked. may need more than one appointment. Patient aware.

Jun 11, 2004, Dr. Terry Ackerman

[Date]231/Jun/2003 [Plan Name]crn send to primary ins with pa- once primary insurance response send to secondary with the duplicate pa

Aug 20, 2026, Dr. Terry Ackerman

Recall exam. Tooth 46: large failing restoration with a fractured cusp and recurrent decay under the margin. Vital, no periapical pathology on today's PA. Remaining restorations sound. Plan: PFM crown 46.

Procedure history

CodeToothDate
02111#46Aug 20, 2026
02144—Aug 20, 2026
11113—Dec 7, 2004
01103—Jun 27, 2003
02601—Jun 27, 2003
27211#12Jun 27, 2003