Daily verification program reconsideration and appeals process
How to request a review of a Canadian Dental Care Plan daily claims verification decision
There is a two-step process in place for oral health providers (providers) to request a review of a daily claims verification decision. First, if a provider disagrees with an adjustment made by Sun Life, they can ask Sun Life to reconsider their verification decision. In the event the provider disagrees with the reconsideration decision they received from Sun life, the provider can proceed to step two and appeal the decision to Health Canada.
This document outlines the reconsideration and appeal process for the daily claims verification program.
Canadian Dental Care Plan Claims Processing and Payment Terms (Billing Agreement)
The Canadian Dental Care Plan (CDCP) Claims Processing and Payment Terms (Billing Agreement) sets out the terms and conditions that govern all claims submitted to the CDCP Benefits Administrator – Sun Life Assurance Company of Canada (Sun Life) for payment. The terms and conditions are applied when making decisions on claims.
Additional details can be found in the CDCP Claims Processing and Payment Terms (Billing Agreement).
Submitting a reconsideration request to Sun Life
Claims submitted to the CDCP could be subject to daily claims verification by Sun Life, which may result in an adjustment. If an adjustment is required, Sun Life will issue the provider a revised Explanation of Benefits outlining the adjustment.
If the provider disagrees with an adjustment made by Sun Life, the provider can request that the daily claims verification decision be reconsidered. A reconsideration request can be submitted by:
Email: isu.admin@sunlife.com
Fax: 1-877-634-3778
Call Centre: 1-888-888-8110
Mail to:
Sun Life
Attn: FRM (CDCP Verification Team)
227 King Street S
PO Box 1601 STN Waterloo
Waterloo, ON N2J 4C5
The request must state that the provider does not agree with the decision rendered and is asking for the daily claims verification decision to be reconsidered. The reconsideration request must reference the original claim number and be accompanied by information to support the reconsideration request.
IMPORTANT: It is the provider’s responsibility to submit all relevant or new documentation at the beginning of the reconsideration process, including information related to other services that support the claim.
Sun Life’s service standard to provide a decision for a reconsideration request is within 30 business days upon receipt. Each case is different, and some decisions could take longer.
Submitting a daily claims verification appeal to Health Canada
If a provider does not agree with the reconsideration decision rendered by Sun Life, they can submit a daily claims verification appeal letter to Health Canada by one of the following methods:
Email: CDCP.CVP.Operations-RCSD.PVR.Operations@hc-sc.gc.ca
Mail:
Health Canada
Oral Health Branch – Claims Verification Appeals
70 Colombine Driveway, Tunney’s Pasture
Brooke Claxton Building, Floor 5, Mail Stop: 0905B
Ottawa, Ontario K1A 0K9
Health Canada will only accept daily claims verification appeals up to 365 calendar days from the original verification decision date, and the assessment of the appeal will be based on information provided to Sun Life during the reconsideration process.
The daily claims verification appeal letter must include the following details:
- The original claim reference number(s);
- The date of the reconsideration decision made by Sun Life;
- The reason for the daily claims verification appeal; and,
- The contact number, mailing address and email address where Health Canada can reach the provider.
Health Canada will assess the daily claims verification appeal by:
- Reviewing the original and reconsideration decisions made by Sun Life;
- Assessing the reason for the appeal;
- Ensuring the decision is aligned with CDCP policies; and,
- Examining the supporting documentation held by Sun Life.
IMPORTANT: Only information held by Sun Life will be assessed in the appeal. Additional information not provided to Sun Life for the reconsideration request will not be considered.
Health Canada’s service standard to provide a decision for a daily claims verification appeal is within 30 business days upon receipt. Each case is different, and some decisions could take longer.
Health Canada’s decision will be provided in the same method the request was received, and this will be Health Canada’s final decision.