Sun Life Financial, US

Contact us

 

Dental Plan FAQ's

Dental Claims Administration

  1. How do I find out about coverage, deductibles, co-pays and maximums for your patients?
  2. Am I required to refer patients to specialists in a patient's PPO network?
  3. How do I submit a claim for one of your patients?
  4. What am I allowed to bill the patient when you apply the alternate benefit provision?
  5. Am I allowed to bill the patient if a service is not paid by you?
  6. Can I send electronic attachments?
  7. Can I check eligibility online?
  8. How do I sign up for electronic claims?
  9. Pre-estimate questions:
    A. How long does it take to process pre-estimates?
    B. What are the guidelines for submitting pre-estimates?
    C. Can I fax pre-estimates to you?
  10. If I have a problem with a claim from you, which number do I call?
  11. If I have a problem with a claim from another company that uses the DHA network, whom do I call?
  12. If I have a dispute with you, how can it get resolved?

How do I find out about coverage, deductibles, co-pays and maximums for your patients?

Please contact Customer Relations at the number indicated on the patient's ID card.

Am I required to refer patients to specialists in a patient's PPO network?

When specialists are required, we recommend that referrals be made to a participating specialist in their PPO network so that patients can take full advantage or their in-network benefits. If you choose to refer a patient to an out-of-network specialist, you may do so, but we request that you inform the patient that they have the option to be referred to an in-network specialist if they desire.

How do I submit a claim for one of your patients?

Claims should be submitted with your usual fees, not the network fee listed in your personal fee profile. Your tax ID number (TIN) should be included on all claims. Claims should be submitted to the address on the back of the patient's ID card.

What am I allowed to bill the patient when you apply the alternate benefit provision?

Many plans contain a provision, which limits the amount of reimbursement for a procedure to the amount available for the least costly alternate treatment for that dental problem or disease. Our PPO dentists are allowed to bill the patient for the service actually performed. The patient's responsibility is the difference paid by us and the fee for the service actually performed. In all instances, you are limited to the charge stated in your Personal Fee Profile.

Am I allowed to bill the patient if a service is not paid by you?

Our PPO dentists are allowed to bill the patient for services performed that are not covered by the plan. For non-covered services, whether the fees are listed in your Personal Fee Profile apply depends on (i) whether you have elected to offer your network fees on non-covered services and (ii) in some cases, any applicable state law. Even if your network fee would otherwise apply, in the event that your usual fee is lower than the network fee, you may not bill the difference between your usual fee and the network fee.

Can I send electronic attachments?

Yes, we accept electronic attachments. Please contact National Electronic Attachment (NEA) for specifics at 770.441.3203, Fax 770.441.3204 or visit www.nea-fast.com .

Can I check eligibility online?

Yes. By logging into Online Advantage where you will be able to search for a particular patient and retrieve their eligibility information.

How do I sign up for electronic claims?

You may contact the WebMD clearinghouse at 615.885.3700.

Pre-estimate questions:

A. How long does it take to process pre-estimates?

It typically takes two or more weeks to process a pre-estimate. Sometimes additional information is needed, so it is helpful to submit all appropriate documentation when filing a pre-estimate. A pre-estimate is recommended on all services over $300.

B. What are the guidelines for submitting pre-estimates?

A pre-estimate is not required but encouraged in order to avoid any confusion about the amount of plan benefits that would be paid.

C. Can I fax pre-estimates to you?

Faxing a pre-estimate is not recommended for those services requiring x-rays for benefit determination. Our fax line for pre-estimates is 563.242.0184.

If I have a problem with a claim from you, which number do I call?

Our Customer Service number is 800.442.7742. Hours of operation are 7 a.m. - 5:30 p.m. CT.

If I have a problem with a claim from another company that uses the DHA network, whom do I call?

Contact the benefits administrator at the phone number on the patient's dental ID card.

If I have a dispute with you, how can it get resolved?

Provider complaints regarding an administrative, payment, or other dispute between the participating provider and the Plan that does not involve a utilization review analysis and does not include routine provider inquiries that the carrier resolves in a timely fashion through existing informal processes should be sent to:

Sun Life Financial/Grievance Department
2745 North Dallas Parkway, Suite 500
Plano, TX 75093

FAX: 855-303-3908
Email: SLFGRIEV@sunlife.com