Provider FAQs

Frequently asked questions (FAQ) for Providers:

Preferred Provider Organization (PPO) topics

Prepaid plan topics


Preferred Provider Organization (PPO) topics

About our PPO Networks

What Preferred Provider Organization (PPO) Networks do you offer?
We offer the Assurant® Dental Network and the Assurant Focus Dental Network®. Our PPO networks include dentists contracted with Dental Health Alliance, L.L.C.® (DHA®) and dentists under access arrangements with other dental networks.

How will I know when a patient participates in one of your PPO networks?
All eligible members will receive an identification card listing their PPO network.

How do I join your PPO networks?
To receive information and forms to join our PPO networks, call Provider Relations at 800-434-2638, email ppoinforequests@sunlife.com or complete this online form. All general dentists and specialists must be credentialed before being accepted as a participating provider. The credentialing process is based on standards developed by the National Committee for Quality Assurance (NCQA) and our provider network.

Is there a fee to join your PPO networks?
There is no fee to join our PPO networks.

How is the quality of the network assured?
We adhere to quality standards encompassing a broad range of care and service issues that are the cornerstone of our Quality Assurance Program (QAP). The program addresses areas of credentialing, utilization reviews, professional standards, the monitoring and resolution of member complaints and appeals, and the assessment of the satisfaction of our providers and eligible members through surveys and evaluations.

How do patients find out that I am a participating dentist?
Your practice information is included in our directory of participating providers and on our website. We also direct patients to participating providers via telephone referrals through our Client Services lines.

Who do I call with questions about my network participation?
You can call Provider Relations at 800-434-2638 from 7:00 a.m. to 4:30 p.m. CT , Monday through Friday.

Who do I call if I have questions regarding my Personal Fee Profile?
You can call Provider Relations at 800-434-2638 with questions, or to obtain your network fee for any procedure not listed in your Personal Fee Profile.

Who do I contact if I have questions regarding my responsibilities with your PPO Networks?
As part of your welcome notification, you were provided a copy of your Participating Dentist Agreement and your Personal Fee Profile. Visit www.dha.com to review The Dentist Guide for guidelines around handling our patients seen in your practice and their claims. We encourage you to refer to this information for any questions you may have. If you have any comments or problems, please call Provider Relations at 800-434-2638.

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Dental Claims Administration

How do I find out about coverage, deductibles, co-pays and maximums for your patients?
Please contact Client Services at the number indicated on the patient's ID card or you can utilize one of our self-service options.

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 Change Healthcare or Tesia.

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 Client Services 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

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Prepaid Plan topics

General Provider Questions

What is the Prepaid Dental Plan?
It is a dental network plan that arranges for provision of covered dental services through a contracted network of private practice dentists. A plan member must see their selected Plan Dentist in order to receive benefits. The member pays any applicable copayment(s) at the time of treatment according to the Copayment Schedule. Except in the case of a dental emergency, services provided by out-of-network dentists are not a covered benefit, unless pre-authorized by the Plan. Except in very limited circumstances, there are no claim forms to submit. You are compensated through the combination of the periodic capitation payment and the member copayment paid at the time of service.

How do I join the Prepaid Plan?
To receive information and forms to join our Prepaid Plan, call Provider Relations at 800-434-2638 or email PrepaidDental@sunlife.com. All dentists and specialists must be credentialed before being accepted as a participating provider. The credentialing process is based on standards developed by the National Committee for Quality Assurance (NCQA) and industry standards.

What states are the Prepaid Dental Plans available in?
We market Prepaid Dental Plans in the following states: Alabama , Arizona , California , Colorado , Florida , Georgia , Illinois , Kansas , Kentucky , Missouri , Nebraska , New Jersey , New Mexico , New York , Ohio , Oklahoma , Pennsylvania , Tennessee , Texas , Utah , and Wisconsin . For a list of the underwriting entities go to our Legal Notice.

General Dentist Provider Questions

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 Clients Services 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 Client Services 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 Client Services 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 Client Services to request assignment to your office. Upon request, Client Services 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.

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 Client Services at 800-443-2995.

How do I know if I have the most current version of the plan Copayment Schedule(s)?
Please contact Client Services 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 Client Services at 800-443-2995.

How can I have a specialist, to whom I refer, added to the network?
Please contact Client Services 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

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Specialist Provider Questions

Do I need a referral to see the patient?
For Legend and Heritage plans: There is no need to obtain a referral prior to treatment of a patient who has the Specialty Benefit Amendment.
For UDC plans: Referral requirements differ for the UDC plans. Please contact Client Services at 800-443-2995.
For DentiCare: A referral is necessary only if the plan has a 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 know if a patient has the Specialty Benefit Amendment?
If you have a question about member benefits or the eligibility of a specific patient, please contact Client Services at 800-443-2995. Our representatives are available to assist you Monday through Friday from 7:00 a.m. to 5:30 p.m. CT.

How do I get reimbursed for services?
Some specialists must submit claims for reimbursement from the plan, as follows:

  • Legend plans with the SBA
  • UDC plans
  • DentiCare plans with the SBR

For all other plans, services performed by specialists are discounted and the patient is responsible for the full discounted reimbursement. Please consult your plan materials or call Client Services at 800-443-2995 for assistance.

What is the Specialty Benefit Amendment (SBA)?
The SBA rider is offered with prepaid plans that provides members enhanced benefits associated with Plan Specialists, plus limited benefits with using a Non-Plan Specialists.

Do all patients have the SBA?
No, please verify whether or not the patient has the SBA before treatment. If the patient does not have the SBA then they are entitled to the applicable discount. 15% discount on endodontic procedures and 25% discount on all other specialty procedures.

How can I receive information about the SBA if I don't currently accept members with the SBA?
Please call Client Services at 800-443-2995. Representatives are available to assist you Monday through Friday from 7:00 a.m. to 5:30 p.m. CT.

Where do I submit an SBA claim for the remaining contracted balance?
Sun Life Financial
PO Box 2940
Clinton, IA 52733

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SLPC 28148 03/17 (exp. 03/19)