The Dental Care Board of Management (NJC Part) is responsible for the overall administration of the Plan, resolving members' complaints regarding eligibility or claims disputes with the Administrator, monitoring the claims settlement performance of the Administrator, and recommending changes to the Plan.
Committee Advisor: Jennifer.Ballantyne@njc-cnm.gc.ca
Quarterly Report to the National Joint Council (September 2019)
Regular activities:
- The Board has met twice (2) since the last Council meeting and examined twelve (12) appeals.
- The Board wishes to note the departure of Dejan Toncic from PIPSC, and thank him for his contribution to the Board.
- The Board reviewed twelve (12) appeals regarding benefits denied for services. Eight (8) were denied in accordance with the limitations of the Plan and three (3) were granted as treatment was deemed to be reasonable and customary. One (1) was granted in part, on an exceptional basis, as the treatment provided was recognized as being consistent with preventative dental care.
- Board members are interested in continuing discussions regarding best practices since a number of appeals relate to preventative measures, supported by evidence-based approaches, yet are not eligible for coverage.
- In addition to receiving regular financial updates from Great-West Life (GWL), Board members participated in a PSDCP Boards of Management meeting to review the 2018 Annual Financial Results.
- At this meeting, members of the NJC and the PSAC dental care plan components expressed concern regarding unusually high amounts of scaling for children and requested that corresponding numbers be provided for the specified age group.
- At a subsequent meeting, the Board received a report from GWL on this issue. The inquiry influenced GWL to include the incidence of abnormal units of scaling for children in their investigations of dental providers.
- The Board also received information from GWL regarding the top dental providers and their gross billings per service category. A comprehensive review of provider performance is also expected to be presented at the next meeting.
- In addition, the Board received information regarding a dental insurance claims audit that had been scheduled to occur a number of years prior. The Board was informed that administrative issues, such as the disclosure of proprietary information could not be agreed upon and as such, the contract to conduct the audit has expired. It was noted that a renewed claims audit is being planned for the future. That said, the Board is concerned with the reasons for abandoning the initial audit given that a review of practices appears to be the purpose of an audit.
- During an update from GWL related to GroupNet, Board members learned about the platform’s new features offering the ability to track a claim, to check eligibility coverages and balances and to calculate the next eligibility date for coverage.
- The Board anticipates a reduction in the amount of appeals for those members who use the application and are seeking promotional opportunities, such as circulating the GroupNet dental video, once available.
Outstanding item(s):
- The Board has three (3) outstanding appeals which are awaiting comments from the Administrator.
Next meeting: February 4, 2020