Important: service provider claims status

#483

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To help protect your benefits plan against increased costs arising from questionable claims, it’s sometimes necessary to disallow claims from certain healthcare service provider(s), clinics, facilities, or medical suppliers (called “provider” below). We refer to this as delisting.

There are many different circumstances that could give rise to delisting. Generally, we take this step because of the provider’s administrative practices. Here are just a few examples of practices that might cause us to delist:

  • a clinic submits an invoice with the name of a provider who does not work at the clinic;
  • a provider fails to validate services or to provide additional information such as clinical records required to determine whether the service or supply is medically necessary; or
  • a provider generates invoices for services for multiple members within a time period during which the number of services could not possibly have been rendered.

In each case, we will consider whether delisting is warranted. Delisting means that Sun Life will cease processing claims from the provider.

What happens when Sun Life “delists” a provider?

When Sun Life delists a provider, you will receive a special Focus Update with the heading “Important:  Delisted provider” to advise that we have delisted one or more providers.

The effective date after which Sun Life will no longer process claims for services will be specified in the communication, along with the name and address of the delisted provider.

Plan member communication

Plan members should know about delisted providers. We will provide you with a standard plan member communication template which we suggest you distribute whenever a delisting occurs. This communication also provides the name, address, claims cut-off date, and instructions on how to view the current list of delisted providers on mysunlife.ca.

The list of delisted providers will remain on mysunlife.ca so plan members can review it periodically. In this way, they can stay current about the delisted providers – and can potentially avoid financial loss from unknowingly using a delisted provider.

Next steps

Please watch for Focus Updates titled “Important:  Delisted provider” so that you and your plan members remain current about Sun Life’s delisted providers.  

Questions?

Please contact your Client Service Administrator at 1-877-786-7227.