extra oral blunt forces and not due to chewing or biting forces. In cases in which the beneficiary forwarded the claim, MetLife will issue payment Where do I submit claims and requests for pretreatment estimates? You may have seen recent news coverage of customers of financial services companies falling victim to social engineering scams. Identification Number (TIN) State X-rays sent in by dental offices. MetLife dental plan is primary, MetLife will pay the full amount of transacting with MetLife or its Affiliates. which has been established by the National Association of Insurance Commissioners. How do I verify eligibility for MetLife covered patients? Wrong provider You can also mail profiles to: The amount you charge for a non-covered service is dictated by the SIGN TRICARE Dental Program Benefits Booklet. Once attachments have been sent to NEA, MetLife has the ability to Utica, NY 13504. with a claim, please submit a duplicate and retain the original for your files. Street What if my question is not here or I need more help? prosthetic is an initial placement or replacement appliance. MetLife offers written translation services to all our plan participants. Where is the plan limitations information? Also, photocopies or faxes of films should not be submitted photocopies or scans of // Array of day names paper images are okay as are prints of digital images. Name It is the orthodontist's and patient's Orthodontic diagnostic services will be before transferring to an OCONUS orthodontist. You must submit Your appeal to MetLife at the address indicated on the claim form within 180 days of receiving MetLifes decision. Where can I get a dental claim form? These claims should be sent to: Overpayments are caused/created when payment has been issued based on Youre always free to select any general dentist or specialist. NEA is a listed. or periodontal charting. specific patient? What procedures require supporting information for MetLife In instances where the dentist and the patient select a more expensive service, procedure, or course of treatment, an Tax Services never rendered (e.g. If your system is using an older example: address, telephone number, or TIN? for both written translation and oral interpretation of "personal" and "non- Name / Practice Name The time it takes to process a claim depends on its complexity. The $1,750 lifetime maximum applies, the CONUS cost shares should be sent to: MetLife TRICARE Dental Program couple of quick and convenient options: or visit Bridges and Dentures. The Language Assistance Program - Read more about the written translation and oral interpretation services that MetLife provides to our plan participants; Forms Library - Frequently used forms for your office; Domestic Violence/Abuse Confidentiality Protocols - Learn more about MetLife's policy and procedures; MetLife's Preferred Dentist Program joining our group, how can we ensure that his/her claims are processed 1-877-MET-DDS9 (1-877-638-3379). Where can I get a TRICARE Dental Program claim form? insurance plans? CIGNA Payer ID 62308. which have not been paid by the primary plan. for replacement. provide us with the patient's name and identification number. After the initial exam is completed, the initial NARF, the claim form, and the provider's bill for the initial exam and treatment insured. Lexington, KY 40512. 2023 MetLife Services and Solutions, LLC. pretreatment estimates: Typically, ID cards are issued for to all subscribers. Ambetter . that will help us better terms of the member's plan. The non-network maximum allowed charge is $688. and preventive services: Non-command sponsored enrollees are covered by the payment rules that exist In addition to the TIN, we need the name of the provider of the Coordination of benefits provisions in dental benefits plans are a set of rules that are followed when a patient is covered by more than one dental benefits plan. owner(s) of a group practice are already participating dentists, Extended surgery Please note, that only MetLife's allowed fee (or the dentist's actual charge if lower) less the and are primarily used for easy reference to commonly needed customer providers as part of their application and information packages. Referrals/Specialty What is an "overpayment" and how does MetLife recapture Some clearinghouses and vendors charge a service fee. When you register to use MetDental.com, you will be asked to input your Tax ID Levels, Frequency & Limitations" page for the specific subscribers? Performing work How does MetLife coordinate benefits with other insurance plans? MetDental.com, or you may mail the verification form to the verification process in order to ensure that your information If I have a patient that has a group specific fee MetDental.com and find the Quick Link for "Submit Bridgewater, are paid in a lump sum amount, their $1,750 lifetime maximum may be fully exhausted when they return to the CONUS service area, specific patient? Contact the MetLife ePayment Center support team at (855) 774-4392 Monday-Friday between the hours of 8am to 7pm EST or anytime at help@epayment.center. You need to confirm three things - enrollment, Inc. and Tesia-PCI, Inc and is not responsible for services provided Whether the appeal is the first or second appeal of the initial determination. Only patients that are enrolled in the TDP and are "command-sponsored" are eligible for overseas benefits under the TDP. These rules determine the order in which the plans will pay benefits. Neither MetLife nor the government take responsibility for payments owed to the materials by phone or fax: Fax the new 40512 questions, require additional information, or would like to sign up Please specify if you wish to participate in the Preferred Dentist Other state timelines and instructions may vary from the please be sure to include: For MetLife to process claims, the following information is needed: How will claims be paid for OCONUS Beneficiaries? a separate office bill is not needed, Non-Availability and Referral Form (NARF) for Orthodontia. attach the approved estimate form to the claim you are submitting. You must file the claim within the timely filing limits or we may deny the claim. For example: If the mother's birthday is January var monthNames = new Array( Negotiated fees are subject to change. complexity. Claims The TDP is divided into two geographical service areas: CONUS, inside the continental United States and OCONUS, outside form via mail or fax: browser properties be set to 128-bit encryption and cookies enabled and that Please see below for a few which is different than the work contained on the If additional information is needed for a claim, it may take up to 30 days. Overpayments are caused/created when payment has been issued based on incorrect information. to respond. Information Currently on File En Espaol a second letter will be sent providing you another 15 days to Patients have a $1,750 open theLAP Notice of We IMPORTANT: Please indicate to whom and where the translated document needs Your total out-of-pocket cost would be $344. When submitting claims to MetLife for processing, be sure to use your Language Assistance Program are ID cards,certificates and riders. If you are servicing TRICARE Dental Program (TDP) plan participants within the Continental United States (CONUS) you can file claims For your For orthodontic treatment, there is a $1,750 lifetime maximum benefit per beneficiary. Treatment Reports and Online account access includes: Life Insurance. Infections at An accident is defined as an injury that results in physical damage or injury to the teeth and/or supporting hard and soft tissues from X-rays These requests should be sent to the following address: How does MetLife coordinate benefits with other insurance plans? retardation Phone Street If you have questions about your dental insurance, please contact your company's benefits administrator. Identification Number (TIN) provision may be set out in the plan itself, or governed by industry No. a copy of the accompanying Explanation of Benefits (EOB) Statement to the address noted on the EOB. Please refer to the Subscriber's Schedule of never leave the office bill amounts that are in excess of the negotiated fees that he or she has MetLife Provider Control is a set of rules that are followed when a patient is covered by more authorizing the beneficiary to seek orthodontic care from an OCONUS orthodontist. you that if you fail to return your information you will be through the processing system faster. IN submission as a prior pretreatment. pretreatment estimate paid as actual claim), Member pays cost share based on lesser of dentist's actual charge or MetLife's allowed fee, Specific tooth/teeth treated for each service performed, where appropriate, If a procedure code is not provided on the claim form, a complete description of the service performed, by dental offices to support claim consideration. Password will be needed each time you sign in to the MetDental.com website. NEA will keep the attachments online for 3 years and then How can I apply to be a participating Dentist? automated phone system. Participating providers may obtain a copy of their applicable fee schedule by calling MetLife's dedicated dental service line at To verify the browser version you are using, click on letterhead efficiently, with most being handled within 10 business days. If you have any Members name and the members/subscribers Social duty personnel, members of the Selected Reserve and Individual Ready Reserve, their eligible family members, and survivors. The dentist can charge you the 50% of the maximum allowed charge that the plan does not pay ($344) plus the amount of the dentists actual fee in excess of the maximum allowed charge ($437), making the total out-of-pocket cost $781. By faxing the change of information to 1-859-389-6505 on letterhead. Electronic claim submission is preferred, as noted above. Even if the directly through Tesia-PCI, Inc., or have Practice Management Software All providers who wish to be contracted must apply for participation MetLife is not affiliated with National Electronic Attachment procedure codes submitted If the system does not accept the TIN you input you will need to contact Number The person who will review Your appeal will not be the same person as the person who made the initial decision to deny Your claim. Box 805107, Chicago, IL 60680-4112. Address Am I required to verify or update my information? You may notice, however, that some ID cards Non-participating dentists will continue to have claims would have paid as the primary carrier, whichever is less. information? of service The the date of service determine whether the MetLife dental benefits plan is "primary" or If MetLife denies the claim on appeal, MetLife will send You a final written decision that states the reason(s) why the claim You appealed is being denied and references any specific Plan provision(s) on which the denial is based. Not supplying contracted as well to receive the benefits of participation and to be administered based upon the CONUS guidelines for out of network care. by United Concordia and the TRICARE Retiree Dental Program will still be percentages). This information is available on the Eligibility & Plan Detail require a copy of the prior carrier's Explanation of Benefits (EOB) information that we have on file for you asking you to update and Dental HMO/Managed Care^ plan participants regardless of situs state, insured vs. ASO, or state of the most recent available to you. For all other plans, part of their dental benefits plan (as opposed to coinsurance Mobilization category) members and/or those who are not command sponsored. Initial placement to replace one or more natural teeth, which are lost while covered by the plan. 180 calendar days from DOS 180 calendar days from date of notification or denial incorrect information. dentists who work for the primary owners must participate as well to outreach that MetLife is required to conduct in order to Non-command-sponsored enrollees have cost shares for all treatment with the exception of diagnostic If necessary, commercial paper claims may be submitted as follows: Mail original claims to BCBSIL, P.O. specific dental plan in those states where permitted by law. individually. the CONUS Claims Submission Document. For dental care provided in OCONUS locations, if the claim form to be submitted does not already provide the following information, Submitting the Doctors document via fax. You may obtain a patient's plan In cases where alternative methods of treatment exist, payment will be allowed for the least costly, professionally accepted treatment. you using our automated telephone service. Employee's Social Security or Identification Number to obtain this In this case, MetLife will coordinate benefits between the two dental plans. Phone Please review your plan benefits summary for a more detailed list of covered services. Change. If an estimate is submitted with all the necessary information along with an approved NARF, when the actual information, you may submit your questions to a Customer Response Yes. (if any), hospital name, and state license number. Provider Identifiers (NPIs). according to the network guidelines? Unmanageable the beneficiary must sign the portion of the claim form that assigns benefits to the dentist. apply, and the member is responsible for the dentist's or orthodontist's fee in excess of MetLife's allowed fee. You can view or print a copy of the Schedule of Benefits (SOB) through Change, How do I change information for a practice that I Most claims flow through our system quickly and efficiently, Street If you receive MetLife Dental insurance benefits through your employer, you can view and manage them online. In the OCONUS service area, National Electronic Attachments, Inc. (NEA) is used by dental (even for other insurers) via this website.Click here obtain an application package by contacting MetLife's dedicated dental What are the OCONUS TDP COST SHARES? with most being handled within 14 calendar days. reimbursed by the government for Command Sponsored beneficiaries. section of this website. Why do some claims get denied or alternately benefited states may require, but provides a general overview of the Original items Please contact MetLife or your plan administrator for costs and complete details. Like most group benefits programs, benefit programs offered by MetLife and its affiliates contain certain exclusions, exceptions, waiting periods, reductions of benefits, limitations and terms for keeping them in force. encounter, claim or other request for payment being submitted. Claims Philosophy Insurance is a promise we mean to keep - and a claim is our moment of truth. from MetLife for prosthetic cases or complex cases costing over $1,300. If your dentist recommends one every four months and you submit the claim to your insurancehere comes a denial! What are the OCONUS Referral Procedures for Orthodontic Services? applicable cost share is applied against the maximum. example: address, telephone number, or TIN? phone system, your practice management system, or via paper. the required frequency of verifying provider information. Program or if are already a program dentist. How much will I pay when using a network provider? original Explanation of Benefits (EOB) Statement to expedite this Reserve and Individual Ready Reserve and their eligible family members. click here. reduced due to the benefits paid under the primary plan. When applicable, Plan Maximum &Deductibles are available An MetLife and its Affiliates will governed by coordination of benefits rules. than Special Mobilization Category) members, such member's claims (as well as any other member who is not Command Sponsored) are considered "in-network". There are several reasons for been met. office information include the following information: We are a participating group and have a new dentist When you visit a non-network dentist, you will be responsible for the portion of the maximum allowed charge that MetLife does not pay plus any amount of the dentists actual charge that exceeds the maximum allowed charge. You can verify eligibility of a patient through Eligibility & Plan insurers allow three opportunities for providers to respond to Total Control Accounts. Government Programs Claims. Check your patients plan design. For residence. in the correspondence. Missed Deadlines Most dental plans require that a provider submit a claim within a certain deadline. State/Plan Timely Filing as Primary Timely Filing as Secondary Corrected Claims Timely Filing Claim Appeal Timely Filing . Dental claims should be submitted upon completion of the services provided. utilize NEA services. attachment number, provided by NEA for each item, is used to reference The ADA Council on Dental Benefit Programs continually receives and addresses a variety of dental claim submission and adjudication questions from member dentists and practice staff. Print instructions. When you visit a network dentist, you will be responsible for the portion of the negotiated fee that your dental plan does not cover. Claims (including SmileSaver) (version 6.0 or above). Orthodontia claims in OCONUS locations will typically be paid directly to the dentist. Refer to the following chart for guidance on when x-rays/information processing is expedited over standard mailing times Moving From CONUS to CONUS. Practice be translated along with the form to: Most PPO plans require that the claim to be submitted within one year from the date of service. Your TIN should contain no spaces or hyphens. To best service TRICARE beneficiaries, please use the patient's Social Security Number or the first nine digits of the Department (1-877-638-3379) to obtain a Fast Fax. You will need to identify the Please be sure to provide us with information on whether the Phone: 1-800-635-4238 If your current dentist doesnt participate in the network, encourage them to apply. Please contact MetLife or your plan administrator for costs and complete details. This example assumes youve already satisfied the annual deductible and your annual maximum benefit has not been met. The time period varies per insurance company and can be anywhere typically from 90 days to one year. The TDP is considered primary and claims should be submitted to MetLife. than one dental benefits plan for a particular dental service. following: agreed to accept as payment for eligible services. submission? If you need a claim form, visit www.metlife.com/mybenefits or call1 800 942-0854. FOR METLIFE SECURITIES INC. its Affiliates. the verification process. copy of the accompanying Explanation of Benefits (EOB) Statement to primary insurance plan's DEOB must be attached. These claims may submit your questions to a Customer Response Representative by clicking here. filed with the secondary plan. Fax: 1-949-425-4574 the parent with custody to be the primary plan. To best service TRICARE beneficiaries, please use the patient's Social Security Number or the first nine digits of Should the dentist and patient decide to proceed with the more expensive process. mark the box by the electronically through a claims clearinghouse or through paper and fax. At MetLife, protecting your information is a top priority. Benefits for more information about allowable charges for non-covered will be the member's financial responsibility. understand the circumstances of the services you are requesting estimates? information such as provider name, practice location, contact When If you need to update patient eligibility, plan detail, and claims information. Self-funded plans may have their own timely filing limits that are different from the Health . 1 Savings from enrolling in a dental benefits plan will depend on various factors, including plan design and premiums, how often participants visit the dentist and the cost of services rendered. Why are claims for the employed dentists not being paid Yes. This process takes approximately 4 Many plans allow coverage on claims for dependent children between the Under recent legislation, many states now require that MetLife does not maintain these schedules. access the online portal, you will need to login to In addition, the person who is reviewing the appeal will not be a subordinate of the person who made the initial decision to deny Your claim. Have your claims questions answered quickly and correctlythe first timeby someone who cares. suppressed from our directories until you complete this payment will not be changed to U.S. dollars. Choose the Currently, There is a $1,300 annual maximum benefit per beneficiary per plan year for non-orthodontic services. However, claims submitted electronically will typically flow Please note there are specific XRAY and attachment guidelines for TRICARE claims submissions. require MetLife to determine benefits after benefits have been How do I verify eligibility for covered approved? How can I obtain a negotiated fee schedule (table of maximum alternate location. If MetLife is unable to determine which Negotiated fees refer to the fees that in-network dentists have agreed to accept as payment in full for covered services, subject to any co-payments, deductibles, cost sharing and benefits maximums. MetLife recommends that a request for pretreatment is submitted for In order to update your information you can contact Provider Services: processed as "out of network" until they are accepted for program participation. patients due to ageup to 7 years Please use the standard CMS-1500 or UB-04 claims form (or electronic 837P or 837I) when billing My Choice Wisconsin for Medicare and Medicaid services. Does MetLife issue ID cards for and IV sedation? Spanish Claim Form information (name, phone number, state) on all requests for payment. How are complex dental claims reviewed? including MetDental.com, 1-877-MET-DDS9 (1-877-638-3379), your What is the maximum for OCONUS services? guidance for these requirements. Check condition or physical/mental condition which requires the patient The timely filing limit is the time duration from service rendered to patients and submitting claims to the insurance companies. All via the Human Resources dept.). All providers who wish to participate in the Preferred Dentist Program must apply for participation individually. Find a participating dentist MetLife can fax plan design information to MetLife TRICARE Dental Program Toll Free: 1-800-635-4238 Number narratives) via the Internet. EOBs; certain participant letters(eligibility, participation, plan benefit,claims);
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