In-depth: Claims Requiring Pre-approvals

In the summer 2019 issue of Viewpoints, we mentioned that we would expand on the topics of Prior Authorization (which refers to Extended Health coverage), and Predetermination (which refers to Dental coverage).

Remember that:

1. For medical services and equipment in excess of $5,000, a preauthorization is required.

2. For certain drug therapies, Sun Life requires prior authorization.

3. For dental procedures that cost more than $500, we recommend that you receive a predetermination from Sun Life.

In these instances, having all the information beforehand can provide an estimate of your potential out-of-pocket expenses, and allow you to make an informed decision prior to using any of these costly services. In this article, we have provided detailed steps on how to send a preauthorization for medical services/equipment, prior authorization for prescription medication, as well as a predetermination for dental services to Sun Life.

Medical Services & Equipment Preauthorization

1. Complete the Extended Health Plan Claim Form, indicating “Preauthorization” on the form.

2. For medical equipment and supplies, 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.

Prior Authorization Program for Prescription Medication (Extended Health Plan)

Prior authorization requires that coverage for certain drug therapies be pre-approved based on certain criteria. For full details, refer to page 14-15 of the Policy Booklet (2017 edition).

If the drug your doctor prescribes for you requires prior authorization, send Sun Life a completed prior authorization form before filling your prescription.

Visit mysunlife.ca/priorauthorization and enter your group Contract Number (020605) for a list of included drugs and forms.

Sun Life will review your request, usually within five business days, and let you know in writing if you are approved and the duration of your approval period.

Please contact Sun Life directly at 1-800-361-6212 if you have any questions.

Predetermination (Dental)

We recommend that you obtain a predetermination from Sun Life before you receive treatment for any dental procedure(s) that cost more than $500.

To receive predetermination for this work, ask your dentist to complete the RSB Dental Claim Form, detailing the dental procedure(s), and then have them send this form to Sun Life for you. Your dentist can also submit this form on your behalf.

Your dentist should include supporting information, such as X-rays or pictures of models or molds, to illustrate the services that are being recommended.

• If your dentist does not provide this information with the form, your predetermination for services will be declined until this information has been received and reviewed by Sun Life.
• Sun Life may also request further information from your dentist as part of its review process.

Once the review process is complete, Sun Life will send you a Claims Statement outlining what part of the cost is covered by the plan and what you will have to pay.

Please contact Sun Life directly at 1-800-361-6212 if you have any questions.

Please note that UBC does not have access to your medical and dental history, which includes preauthorizations, prior authorizations, and predeterminations. If you have questions regarding the status of your pre-approval requests, please contact Sun Life directly at 1-800-361-6212.