Preauthorizations and Predeterminations Explained

Under the UBC Extended Health plan, claims for medical equipment costing $5,000 or more require preauthorization prior to purchase.¹ Under the UBC Dental Plan, any major treatment of $500 or more requires a predetermination prior to the treatment.²

However, if you find a recommended treatment plan or medical device to be cost-prohibitive, Sun Life will provide you with a preauthorization or predetermination free of charge.

Sun Life will first determine whether coverage is available to you, and if so, how much of the cost will be covered by your UBC Extended Health or Dental plan. This information will help you determine whether to move forward with the recommended treatment or purchase and could also be helpful if you decide to speak to your provider about an alternative treatment.

How do I request a medical services and equipment preauthorization or a dental predetermination?

Medical Services & Equipment Preauthorization

1. Complete the appropriate Extended Health Plan Claim Form for your employee group, indicating “Preauthorization” on the form.
2. For medical equipment and supplies, please make sure that the estimate includes the following information:

• Date of purchase
• Claimant’s name
• Item description, including make and model name if available
• Quantity
• Price
• Physician’s name
• Proof of the portion paid by the province in which the service or medical equipment was obtained (if applicable)
• Receipts must be legible and each expense must be listed separately and clearly indicated.
• Cash register receipts are acceptable if the name of the product is included, a physician’s referral is attached, and/or the name of the patient is indicated on a signed claim form.
• If the receipt is for a brace, please indicate the body part (e.g. left knee brace).

3. Attach the recommendation from your physician (if required).
4. Make copies of all the above and mail to the nearest Sun Life Claim Centre as indicated on page 2 of the claim form, or submit the estimate using the “send documents” feature on the Sun Life Mobile app.

Dental Predetermination

Many dental offices will electronically submit predetermination requests to Sun Life on your behalf. If your dental office prefers to submit predetermination requests on paper, have the dental office:

1. Complete the appropriate Dental Plan Claim Form for your employee group, indicating “Predetermination” on the form.
2. Ensure any x-rays or models are included with the request, if applicable.
3. Have the dental office send this request to the nearest Sun Life Claim Centre as indicated on page 2 of the claim form.

Once Sun Life has reviewed the claim, they will mail a Claimant Statement to your home address. If you have registered for access to the Sun Life Plan Members’ website, you will be notified that the Claimant Statement is available for download.

References:

¹ Preauthorization is required and it is a request for preapproval for reimbursement of medical services and equipment under the Extended Health benefits plan.

² Predetermination is recommended and it is a fee estimate submitted to Sun Life. Sun Life will advise you and your dentist what portion of the fees will be reimbursed under the Dental plan.