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Dental Plan FAQ's

General Dentist Provider Questions

  1. How does the Prepaid Plan work?
  2. How do I know which plans I accept?
  3. How do I refer my patient to a specialist?
  4. How do I verify patient eligibility?
  5. Do plan members have to assign me as their Plan Dentist to receive benefits?
  6. Do I need to submit a claim?
  7. Can I file claims for the difference in copayments and costs?
  8. How do I know if I have the most current version of the plan Copayment Schedule(s)?
  9. What happens if the procedure I performed is not listed on the Copayment Schedule?
  10. How can I have a specialist, to whom I refer, added to the network?
  11. If I have a dispute with you, how can it get resolved?

How does the Prepaid Plan work?

Members select a Plan Dentist from our directory at time of enrollment. We will send you a roster each month listing the members who have selected your practice as well as plan they have purchased. You will receive monthly capitation payments for these members and you will collect copayments from the members based on the plan and the service you perform. Member discounts are identified in the applicable Copayment Schedule. Except in rare circumstances, such as an out-of-area emergency, member may only access the benefits of the plan by seeing you, the selected Plan Dentist.

How do I know which plans I accept?

Your roster will list all the members that have selected your practice along with the plans that they have purchased. If you have a question about the plans listed or need copies of the Copayment Schedules, please contact Customer Relations at 800.443.2995. Representatives are available to assist you Monday through Friday from 7:00 a.m. to 5:30 p.m. CT.

How do I refer my patient to a specialist?

The requirements for specialist referrals vary by plan and in some cases by state, as follows:

For Legend and Heritage plans: No referral is necessary. If the plan has the Specialty Benefit Amendment, your patient has the option to receive their specialist care from a specialist that participates with our plan or they may seek care from any specialist. Exception: members in Colorado , Florida or Arizona are required per a state mandate to receive their specialist care from a participating network dentist.

For UDC plans: Referral requirements differ for the UDC plans. Please contact Customer Relations at 800.443.2995.

For DentiCare plans: A referral is necessary only if the plan has the Specialty Benefit Amendment.
In all cases where an emergency referral to a specialist is required, the general dentist can call in an emergency referral.

How do I verify patient eligibility?

Your monthly roster will list all the members that have selected your practice along with the plan that they have purchased. If you have a question about your monthly roster or the eligibility of a specific patient, please contact Customer Relations at 800. 443.2995. In addition, you can access eligibility online.

Do plan members have to assign me as their Plan Dentist to receive benefits?

Yes, members need to select your office to be listed on your roster to receive benefits based on the Copayment Schedule. The member should call Customer Relations to request assignment to your office. Upon request, Customer Relations can verify the assignment of the member to your practice over the phone or via fax. Representatives are available to assist you Monday through Friday from 7:00 a.m. to 5:30 p.m. CT at 800.443.2995.

Do I need to submit a claim?

Plan Dentists do not need to submit claims. You will collect any applicable copayment directly from the member. The member is responsible for payment of the copayment amount as listed on the plan schedule of benefits at the time of service unless you make other arrangements with the member.

Can I file claims for the difference in copayments and costs?

No, the copayments listed on the Copayment Schedule are the full amounts the member is responsible to pay to the Plan Dentist. Services not listed on the Copayment Schedule are not covered by the Plan. If services not listed on the Copayment Schedule are necessary, you may bill the patient at your normal retail charge. Refer to your plan information for specific guidelines or call Customer Relations at 800.443.2995.

How do I know if I have the most current version of the plan Copayment Schedule(s)?

Please contact Customer Relations at 800.443.2995, Monday through Friday from 7:00 a.m. to 5:30 p.m. CT to request a copy of the most current Copayment Schedules.

What happens if the procedure I performed is not listed on the Copayment Schedule?

First, please verify that you have the most current version of the Copayment Schedule. Services not listed on the Copayment Schedule are not covered by the Plan. If those services are necessary, you may bill the patient at your normal retail charge. Refer to your plan information for specific guidelines or call Customer Relations at 800.443.2995.

How can I have a specialist, to whom I refer, added to the network?

Please contact Customer Relations at 800.443.2995 and provide us with the name of the specialist you would like for us to contact. We will have a Provider Relations representative contact the office as quickly as possible.

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