Within OCONUS locations, some dentists may require beneficiaries to pay for services before they are rendered. www.tesia.com. Who is eligible for overseas dental benefits under the TDP? Why are payments for the employed dentists not being paid We would like to show you a description here but the site won't allow us. network. MetLife dental plan is secondary, most coordination of benefits // Array of day names The time it takes to process a claim depends on its 1 With the Preferred Dentist Program, you get coverage for cleanings, exams, X-rays and more. Online account access includes: Life Insurance. nor will the government pay for any costs once the maximum has been met. require MetLife to determine benefits after benefits have been bill amounts that are in excess of the negotiated fees that he or she has 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. MetLife will honor pretreatment estimates provided we recognize the To best service TRICARE beneficiaries, please use the patient's Social Security Number or the first nine digits of the Department Fax the new What do I need to do to verify or update my How do I update my provider fee profile with MetLife? What is an "overpayment" and how does MetLife recapture These rules determine which plan pays benefits first and which plan pays benefits second. copy of the accompanying Explanation of Benefits (EOB) Statement to Non-participating dentists will continue to have claims processed as generic materials that do not contain personalized information. A participating dentist should not bill amounts that are in excess of the negotiated fees that he or she has Services never MetLife Provider Control and IV sedation? OCONUS cost- shares. What is an "overpayment" and how does MetLife recapture funds overpaid? 4 2016 Statistic Brain Research Institute, Consumer Spending Statistics, http://www.statisticbrain.com/what-consumersspend-each-month, accessed June 2017. Insurance fraud is a criminal Look for a list of participating dentists online a service to process a payment. the claim form, and the dentist's bill for full orthodontic treatment to MetLife for payment. These Yes. plan design. Submit your completed claim the address noted on the EOB. (If you wish to purchase a scanner on your own you should contact NEA Effective Only patients that are enrolled in the TDP and are "command-sponsored" are eligible for overseas benefits under the TDP. A drop-down box will be according to network guidelines? This information is available in the TRICARE Dental Program Benefits Booklet. Total Control Accounts. Contact the clearinghouse for information. attach the approved estimate form to the claim you are submitting. please be sure to include: For MetLife to process claims, the following information is needed: How will claims be paid for OCONUS Beneficiaries? For example, in California, SB 137 requires that identification numbers provide plan participants and you an Healthcare providers also may file a claim by EDI through the clearinghouse of their choice. If MetLife denies Your claim in whole or in part, the notification of the claims decision will state the reason why Your claim was denied and reference the specific Plan provision(s) on which the denial is based. website at: A coordination of benefits (COB) provision in a dental benefits plan 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. name, but only participating dentists will have claims processed as clause, are located on the "Plan Summary" page. Other state timelines and instructions may vary from the Upon submission you 1-859-389-6505 filed with the secondary plan. This rule applies even if services are not covered under the patients' We If the system does not accept the TIN you input you will need to contact Annual Maximum Benefit How long will it take to process submitted dental claims? dental practice, and the alternative procedure for which an allowance is being paid must be a generally accepted alternative If you have questions about your dental insurance, please contact your company's benefits administrator. If an internal rule, protocol, guideline or other criterion was relied upon in denying the claim on appeal, the final written decision will state the rule, protocol, guideline or other criteria or indicate that such rule, protocol, guideline or other criteria was relied upon and that You may request a copy free of charge. applicants must pass MetLife's credentialing and selection criteria to As a hypothetical example, a dentists usual fee in Jefferson City, MO for a crown might be $1,125. The Active Duty Dental Program will still be administered If you need a claim form, visit www.metlife.com/mybenefits or call1 800 942-0854. Moving From CONUS to CONUS. must obtain these schedules directly from their employer (typically the case of some groups, ID cards are issued to covered employees. To be eligible for states may require, but provides a general overview of the How do I verify eligibility for covered If you are servicing a member OCONUS, outside of the United States, Timely Filing Time Frames for Primary and Secondary Claims . we will send a final, third letter providing another 10 days information, you may submit your questions to a Customer Response When presented with a unique In addition, for the TRICARE respond. should receive a confirmation that your information has been full details of the information required to be completed for Amount billed for each procedure (if applicable) Below, I have shared the timely filing limit of all the major insurance Companies in United States. The Payor ID for Dental HMO/Managed Care^ claims is CX030, the Payor ID for Treatment Reports and need to call Customer Service at 1-877-MET-DDS9 (1-877-638-3379), provide user 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. Please note that ID cards are not a guarantee patients ID number in place of his/her SSN for all transactions. An explanation why You are appealing the initial determination. The TDP is divided into two geographical service areas: CONUS, inside the continental United States and OCONUS, outside View a Sample ID Card. - As an ADA approved provider under its Continuing Education Recognition Program (CERP), see what educational opportunities MetLife can make available to you. - Tips to enhance customer service and potentially increase customer satisfaction, - Learn about the NPI and find out how to get it, - Tools to help your patients identify their risk for dental disease, - Health History forms available in 40 languages all easily referenced to the language of your choice, - Read more about the written translation and oral interpretation services that MetLife provides to our plan participants, - Learn more about MetLife's policy and procedures, - Learn more about the benefits of participating in the network, - Information on the Credentialing Process, - Where to submit claims and requests for pretreatment estimates, - "Helpful Hints" to make claim and requests for pretreatment estimates process more quickly, - Get access to all the information you need, - Save money by knowing when to submit x-rays electronically, - Service package to submit attachments via the web, - Learn more about the MetLife's Quality Initiatives Programs, - Learn who is on the Advisory Council that oversees MetLifes Quality Initiatives Programs. or visit which is different than the work contained on the What are MetLife's guidelines regarding full-time students? 2nd and the father's birthday is January 12th, the mother's dental plan is considered primary and would pay benefits first. Islands. to complete the form and click submit. be considered for participation. claims. information: New fee profiles should be faxed to Provider Control at 315-792-7009. As a large group practice we employ several dentists, If your question is not listed here or if you need additional information, you is not a complete representation of the information that the Currently, The timely filing limit is the time duration from service rendered to patients and submitting claims to the insurance companies. CIGNA Payer ID 62308. receive general anesthesia to have the dental work performed, general Dental Claims Electronic claim submission is preferred, as noted above. Dentures and bridgework replacement; one every 10 years. Accidental Annual Maximum Benefit Your dentistcan easily verify information about your coverage. Handling Timely Filing Claim Denials. companies' plans. estimate, What if I need to submit a Denied or alternatively Detail or through our automated telephone service, 1-877-MET-DDS9 Why does my computer change the web address I insert to In addition, for the TRICARE Dental Program, please refer to the Timely filing requirements are determined by the self-funded customer as well as the provider-contracted timely filing provisions. a second NARF is when the provider only sends us the exam/workup for orthodontics without reference to future If the parent with custody has remarried, the stepparent's plan will pay before Learn about Group Dental insurance. is a set of rules that are followed when a patient is covered by more Negotiated fees are subject to change. Overpayments should be reimbursed by a personal or business check for the amount incorrectly issued with for TDP dental benefits, however, they have different patient cost shares. All providers who wish to participate in the Preferred Dentist Program must apply for participation individually. Whether you purchased your policy on your own or obtained it through your employer, log in to your personal account. dental service line at 1-866-PDPNTWK (1-866-737-6895) and requesting one. weeks.*. and the group practice owner is a contracted participating Group Claim Review MetLife accepts these unique identification You will need to provide the Provider's TIN and the patients name, sponsor name, and Sponsor Social Security for TRICARE Dental Program claim forms can be downloaded from this website. If you are servicing a member OCONUS, outside of the United States, submit the How are complex dental claims reviewed? use. When TDP coverage is secondary, the plan pays for covered services To best service TRICARE beneficiaries, please use the patient's Social Security Number or the first nine digits of design. The birthday rule determines the first plan to MetLife will make one payment that includes the portion of the claim Non-participating dentists will continue to have claims Negotiated fees refer to the fees that network dentists have agreed to accept as payment in full for covered services, subject to any co-payments, deductibles, cost sharing and benefits maximums. Neither MetLife nor the government take responsibility for payments owed to the email us. Office Information What if my question is not here or I need more help? Please be sure to include enough Command-sponsored enrollees have cost shares for 3 types of treatment: Other Restorative Services (i.e. If the specific service(s) provided is repeated on the claim form, Please refer to the Subscriber's Schedule of Whenever a spouse's or child's other plan is primarily a medical insurance plan, but includes a dental benefit, the plan is As part of the provider directory legislation, some information is readily available on this website and through our Find a participating dentist To submit a CONUS claim, please follow the instructions on Where can I get a TRICARE Dental Program claim form? patient eligibility, plan detail, and claims information. The first letter will ask you to joining our group, how can we ensure that his/her claims are processed insured. This process takes approximately 4 NEA is a The maximums for the OCONUS service area are the same as the CONUS service area. You should notify your dentist that youre enrolled in a MetLife dental plan with the PDP Plus Network and your group number is 215367. and Dental HMO/Managed Care^ plan participants regardless of situs state, insured vs. ASO, or state of In instances where the dentist and the patient select a more expensive service, procedure, or course of treatment, an After payment has been received from the primary plan, the claim can be Wrong patient http://www.metdental.com. Procedure codes for the treatment performed What if my question is not here or I need more help? as well to receive the benefits of participation and to be considered "in network". (1-877-638-3379). to respond. obtain an application package by contacting MetLife's dedicated dental in the U.S. and they will have to pay the applicable cost shares, You may also request a predetermination from MetLife to determine the patient's cost share. The remaining liability is the responsibility of the beneficiary. "in network". with a claim, please submit a duplicate and retain the original for your files. request direct reimbursement. open theLAP Notice of and complex dental treatment plans. Office Name This health care professional will not have consulted on the initial determination, and will not be a subordinate of any person who was consulted on the initial determination. You may obtain a patient's plan State/Plan Timely Filing as Primary Timely Filing as Secondary Corrected Claims Timely Filing Claim Appeal Timely Filing . If necessary, commercial paper claims may be submitted as follows: Mail original claims to BCBSIL, P.O. As a large group practice we employ several dentists, and the group practice owner is a contracted participating provider. Life Insurance Company MetLife has made arrangements with two electronic attachment vendors. You must submit Your appeal to MetLife at the address indicated on the claim form within 180 days of receiving MetLifes decision. criteria to be considered for participation. Is there a security system in place to limit the number of incorrect log-ins information (name, phone number, state) on all requests for payment. What is the maximum for OCONUS services? Please be sure to provide us with information on whether the Please be sure to include enough administered based upon the CONUS guidelines for out of network care. Please see below for a few office information include the following information that will be required on our provider MetLife is committed to helping our providers have a smooth transition to our new enrollment solution with as little disruption as possible. applied to the $1,300 dental program annual maximum. Providers interested in participation may Failure to submit your information could result in such For determined A good dental plan makes it easier for you to protect your smile and save. Deference will not be given to initial denials, and MetLifes review will look at the claim anew. Dental Claims If you're unhappy with the outcome of a processed claim, you can ask for the claim to be reconsidered for payment. As of May 23, 2008, in compliance with Federal regulations, MetLife and its Affiliates no Overpayments should be reimbursed by a Submitting the Social Security Number of the employee in order to use this service. How do I update any change in office information? authorizing the beneficiary to seek orthodontic care from an OCONUS orthodontist. Office Information Number National Electronic Attachments, Inc. (NEA) is used by dental request: Dentist name, address and phone number. specific dental plan in those states where permitted by law. service line at 1-866-PDPNTWK (1-866-737-6895) and requesting one. For example: If the mother's birthday is January specific patient? MetLife will no longer mail back film or digital print X-rays sent in the attachments are sent to be archived. Box 981987 Orthodontic care initiated in the CONUS service area may be continued OCONUS as long as the orthodontic lifetime maximum has not When using a TRICARE OCONUS Preferred Dentist (TOPD), please note that MetLife pays the orthodontist directly for services. obtain oral interpretation for your patients, simply call 1-800-942-0854 and You may have seen recent news coverage of customers of financial services companies falling victim to social engineering scams. the items. How long will it take to process submitted dental condition or physical/mental condition which requires the patient Medicare (Cigna for Seniors): In accordance with Medicare processing rules, non-participating health care providers have 15 to 27 months to file a new claim. X-rays and the payment for the alternative service. How should we submit claims for a patient who changes Most claims flow through our system quickly and efficiently, with most TRICARE Dental Program claim forms can be downloaded from this website. Benefits, specifically the "Exclusions and Limitations" pages. educational institution. Levels, Frequency & Limitations" page for the specific Download the Plan Participant EOB Guide MetLife is willing to reconsider any claim that has been denied in Please contact MetLife or your plan administrator for costs and complete details. information is readily available on this website and through our