You may choose a new one once a month. WebYou may choose one of four dental plans, offered by SafeGuard, a MetLife Company and Metropolitan Life. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. WebWe would like to show you a description here but the site wont allow us. endstream endobj 4796 0 obj <>stream H|y\GozfKQgxDxk5Q"E[/P# GYf>WWU]z #Fv;t|*DDG&)07"jnlM&r3fLIsg@L?2t&&:r@p>_hwxwm!1IcNp,<6nfT^IAI. It sets what they can charge for covered services. The ADA anticipates that the costs of providing care will substantially increase for many dental procedures. Your benefits plan determines coverage. Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". Aetna Inc. and itsitsaffiliated companies are not responsible or liable for the content, accuracy or privacy practices of linked sites, or for products or services described on these sites. Before you provide certain services, you will need to submit authorization request forms. Virginia members: In Virginia, DMO is called DNO (Dental Network Only). Questions may be directed to Humana provider relations by calling 1-800-626-2741, Monday Friday, 8 a.m. 5 p.m., Central time. 0000050787 00000 n Contact Us. This excerpt is provided for use in connection with the review of a claim for benefits and may not be reproduced or used for any other purpose. In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. Sign up at BeneFeds.com or call 1-877-888-3337. WebCleaning for adults is covered every three months. Benefits provided by SafeGuard Health Plans, Inc., a MetLife company. WebMetLife strongly recommends that you have your dentist submit a pretreatment estimate to MetLife if the cost is expected to exceed $300. 0000044288 00000 n 0000017092 00000 n Hn0R`~(dQQl\0H5oKtFA?v>4.zL >.K;J+p0eLK!YWU-`}\~nxqC79*G: >$LAFMEECJ.&rwBx77C(gOI CHAwl"4Q !b p^y2gp#M Vision hardware fee schedule is available through the ESD contract. The ABA Medical Necessity Guidedoes not constitute medical advice. Choose a primary care dentist who participates in our network. %PDF-1.4 % Links to various non-Aetna sites are provided for your convenience only. Aetna defines a service as "never effective" when it is not recognized according to professional standards of safety and effectiveness in the United States for diagnosis, care or treatment. As a MetLife Vision customer you can access language 0000072009 00000 n xref DMO plans require a surgical periodontal history. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. I was billed more than the standard $150 co-payment for a crown. Treating providers are solely responsible for medical advice and treatment of members. metlife dental claim form NCFlex MetLife Triple Options Booklet and FAQs NCFlex MetLife Dental International Travel Assist Flyer MetLife Dental Low Option Certificate 01 01 20 MetLife Dental Low Option Certificate UNC Chapel Hill 01 01 20 MetLife Dental Classic Option Certificate 01 01 20 TmEg=boq1c8-,4%n (x@q U?eVzfK@X^=|?UOeq}:C |zYlK$"91q''o%$D?('N.. Therefore, it is crucial to verify benefits and eligibility with the Payor. Signing up is simple and free. Hn0} WebCan I get an estimate of my out-of-pocket expenses? This Agreement will terminate upon notice if you violate its terms. You can see if your plan has a work-in-progress exclusion. WebYou can obtain an updated procedure charge schedule for your area via fax by dialing 1-800-942-0854 and using the MetLife Dental Automated Information Service. You may not have coverage to replace teeth that were lost or extracted before your coverage began. _t Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. w)A7ilBnx_^bu>3E;LU,Nhs%v1&OvC:-R/mTpm:3]q%ih*N Aetna's conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna). 163 0 obj <> endobj In case of a conflict between your plan documents and this information, the plan documents will govern. Or call Member Services for coverage details. 797 0 obj <>/Filter/FlateDecode/ID[<37A34B695481DA4B83FCA71461750ABE><99A26598FF436C418BD6EB0A4885ABA5>]/Index[779 47]/Info 778 0 R/Length 98/Prev 235657/Root 780 0 R/Size 826/Type/XRef/W[1 3 1]>>stream WebThe sequestration reduction amount for each affected claim will be identified on the explanation of remittance healthcare providers receive from Humana. How do I notify PEBB that my loved one has passed away? hbbd```b`` Oral surgery You pay 20% of covered services for basic surgery; 50% of covered major surgery. You can view and print your ID card from your member website. We need to authorize the use of a different provider before treatment. The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Metropolitan Life Insurance Company, New York, NY 10166 !f"UF =,T).ts 825 0 obj <>stream You may still elect to receive services from a non Every enrolled family member may select their own primary care dentist. CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. Plus, you'll enjoy: More than 400 covered services 2. Include North/South/East/West with address if appropriate. 0000017206 00000 n Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. and itsaffiliated companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites. RLaVHQB-JS=*ccYqE,cD98q:A-H}D+&\jC80n 3"Dtd(DDhy +pE8ai:H,[9"XX$'8ZD` t'+"1:wu0.Zg*e ^Eya}uqUUF)j^c[d8unIq:J_|u[#,gNj[bS }|2"X$^=O\.agtV|1`G~eY)ez_!+!:v*J Q(v~RppZpccCSZgc3p7~{1^zVEQ5+c1 ;{ycu$g@y&A|d(:6e FkG=^:s`P$aq/lX}N970/k You can get a Summary of Benefits from your employer that provides your insurance. How do providers identify the correct payer? Copyright 2015 by the American Society of Addiction Medicine. The member's benefit plan determines coverage. This comprehensive listing of fee maximums is used to reimburse a physician and/or other providers on a fee-for-service basis. Find a dentist near \Jc sVB;xN"#~D=1GE SJ4{[HM`|x>~y\YgO_YQ la70'1!!7FY%^P\iRk*#L n~^IJ54g+Rq k (C8y}H7=s2TiUfS^|d yfGBak44\@j These services include: We may not cover services youve received without coverage. Finding the right dentist is easy with the MetLife dental network, which includes over 146,000 providers Visit providers in or out of network with our flexible plans Members benefit from our negotiated fees, which are typically 30-45% less than average Some Quick Facts About MetLife You are now being directed to CVS Caremark site. This SCHEDULE OF BENEFITS lists the Covered Services available to You and Your Dependents under Your dental plan, as well as Your and Your Dependents costs for each Covered Service. They do so as if there is no secondary payor. endstream endobj 4805 0 obj <>stream 0000001499 00000 n WebMetLifes Table of Maximum Allowable Charges or Fee Schedule applies to dental procedures performed on eligible members participating in MetLifes Preferred Dentist 0000043626 00000 n %%EOF The Apple Health PDL can be found on the agency's Apple Health PDL page. ", The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. WebNot all employer groups associated with these Payors will utilize the Connection Dental Network. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Clinical Policy Bulletins (CPBs). WebFind a Dentist. 0000136750 00000 n When billing, you must use the most appropriate code as of the effective date of the submission. Yes. endstream endobj 164 0 obj <>/Metadata 15 0 R/Pages 14 0 R/StructTreeRoot 17 0 R/Type/Catalog/ViewerPreferences<>>> endobj 165 0 obj >/PageTransformationMatrixList<0[1.0 0.0 0.0 1.0 -306.0 -396.0]>>/PageUIDList<0 152>>/PageWidthList<0 612.0>>>>>>/Resources<>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/Rotate 0/StructParents 0/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 166 0 obj [/Separation/PANTONE#20376#20C/DeviceCMYK<>] endobj 167 0 obj [/Separation/PANTONE#20347#20C/DeviceCMYK<>] endobj 168 0 obj [/Separation/PANTONE#202995#20C/DeviceCMYK<>] endobj 169 0 obj <> endobj 170 0 obj <>stream 0000036990 00000 n They arent a PCD. Check your Aetna Summary of Benefits. H=o0w7S4oA2dhQ,QITEF}v@DN/8LBl^K]H*f:J]yDyS{dZ>L80|8xa@c7iCSY_yLdZ~2}e$LJV\+8CG09s^@wg8pn@\O9C3b\ O1^7TR6:'o9vS rp:QM{9l-k[[@szQV[*P/0chT}($^X'F-Bw)t]V[atF5]@R,hYxk,7Ge^AF*Ul. Bzb:5Gl8%bYYFMG`L"J/rrkBlF)ltPBVW oz For previous versions, email us applehealthpharmacypolicy@hca.wa.gov. The term precertification here means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company's clinical criteria for coverage. $10 to $50 to extract a tooth. 0000136999 00000 n Visit our Document submission cover sheets page to find the barcode cover sheets required with additional documentation. 0000021213 00000 n L0621014064[exp0622][All States]. HtTYo@~0IOHC Log in to your member website first to get personalized results. 0000037307 00000 n CPT only Copyright 2022 American Medical Association. If so, we will confirm which plan has primary responsibility for claim payment. cy The information you will be accessing is provided by another organization or vendor. Each DMO member must select a PCD. endstream endobj 4801 0 obj <>stream Have your dentist send a pretreatment estimate (predetermination) to us. HTn0?N$vt.taQ"]QI~}kGvc:PXJ ,DDIuEE}%uDp'QMXzm:h?cZH;%*E[*& August 1, 2022 to present Neurodevelopmental centers billing guide, July 1, 2022 to July 31, 2022 Neurodevelopmental centers billing guide, July 1, 2021 to June 30, 2022 Neurodevelopmental centers billing guide, View all neurodevelopmental centers billing guides, July 1, 2022 to present Neurodevelopmental centers fee schedule, July 1, 2021 to June 30, 2022 Neurodevelopmental centers fee schedule, January 1, 2021 to June 30, 2021 Neurodevelopmental centers fee schedule, View all neurodevelopmental centers fee schedules, January 1, 2019 to March 31, 2019 Nondurable medical supplies and equipment billing guides, July 1, 2018 to December 31, 2018 Nondurable medical supplies and equipment billing guides, View all nondurable medical supplies and equipment billing guides, January 1, 2019 to March 31, 2019 Nondurable medical supplies and equipment fee schedule, April 1, 2023 to present Nursing facilities billing guide, January 1, 2023 to March 31, 2023 Nursing facilities billing guide, October 1, 2022 to December 31, 2022 Nursing facilities billing guide, View all nursing facilities billing guides, April 1, 2023 to present Orthodontic services billing guide, January 1, 2023 to March 31, 2023Orthodontic services billing guide, October 1, 2022 to December 31, 2022 Orthodontic services billing guide, View all orthodontic services billing guides, August 1, 2022 to present Outpatient hospital services billing guide, July 1, 2022 to July 31, 2022 Outpatient hospital services billing guide, April 1, 2022 to June 30, 2022 Outpatient hospital services billing guide, April 1, 2023 to present -- OPPS fee schedule, January 1, 2023 to March 31, 2023 OPPS fee schedule, October 1, 2022 to December 31, 2022 OPPS fee schedule, July 1, 2022 to September 30, 2022 OPPS fee schedule, April 1, 2022 to June 30, 2022 OPPS fee schedule, January 1, 2022 to March 31, 2022 OPPS fee schedule, October 1, 2021 to December 31, 2021 OPPS fee schedule, August 1, 2022 to present Outpatient rehabilitation billing guide, July 1, 2022 to July 31, 2022 Outpatient rehabilitation billing guide, January 1, 2022 to June 30, 2022 Outpatient rehabilitation billing guide, View all Outpatient Rehabilitation Program billing guides, July 1, 2022 to present Outpatient rehabilitation fee schedule, July 1, 2021 to June 30, 2022 Outpatient rehabilitation fee schedule, January 1, 2021 to June 30, 2021 Outpatient rehabilitation fee schedule, View all Outpatient Rehabilitation Program fee schedules, July 1, 2022 to present Pharmacy Special Services fee schedule, July 1, 2021 to June 30, 2022 Pharmacy Special Services fee schedule, July 1, 2020 to June 30, 2021 Pharmacy Special Services fee schedule, View all pharmacy special services fee schedules, May 1, 2023 to present - Physician-related services/health care billing guide, April 1, 2023 to April 31, 2023 Physician-related services/health care billing guide, January 1, 2023 to March 31, 2023 Physician-related services/health care billing guide, View all physician-related/professional services billing guides, April 1, 2023 to present Physician-related services fee schedule, January 1, 2023 to March 31, 2023 Physician-related services fee schedule, October 1, 2022 to December 31, 2022 Physician-related services fee schedule, View all physician-related/professional services fee schedules, January 1, 2023 to present Enhanced pediatric fee schedule, July 1, 2022 to December 31, 2022 Enhanced pediatric fee schedule, October 1, 2021 to June 30, 2022 Enhanced pediatric fee schedule, View all enhanced pediatric fee schedules, January 1, 2023 to present Enhanced adult primary care fee schedule, July 1, 2022 to December 31, 2022 Enhanced adult primary care fee schedule, October 1, 2021 to June 30, 2022 Enhanced adult primary care fee schedule, January 1, 2023 to present Opioid use disorder fee schedule, July 1, 2022 to December 31, 2022 Opioid use disorder fee schedule, July 1, 2021 to June 30, 2022 Opioid use disorder fee schedule, View all medication for opioid use disorder fee schedules, July 1, 2022 to present Conversion factors, July 1, 2021 to June 30, 2022 Conversion factors, July 1, 2020 to June 30, 2021 Conversion factors, Centers of Excellence: organ transplant facilities directory, April 1, 2023 to present Planned home births and births in centers billing guide, January 1, 2023 to March 31, 2023 Planned home births and births in centers billing guide, October 1, 2022 to December 31, 2022 Planned home births and births in centers billing guide, View all planned home births billing guides, January 1, 2023 to present Planned home births and births in centers fee schedule, July 1, 2022 to December 31, 2022 Planned home births and births in centers fee schedule, July 1, 2021 to June 30, 2022 Planned home births and births in centers fee schedule, View all planned home births fee schedules, July 1, 2022 to present Prenatal diagnosis genetic counseling fee schedule, July 2021 to June 30, 2022 Prenatal diagnosis genetic counseling fee schedule, July 1, 2020 to June 30, 2021 Prenatal diagnosis genetic counseling fee schedule, View all prenatal diagnosis genetic counseling fee schedules, January 1, 2023 to present Prescription drug program billing guide, April 1, 2022 to December 31, 2022 Prescription drug program billing guide, October 1, 2021 to March 31, 2022 Prescription drug program billing guide, January 1, 2023 to present Expedited authorization codes and criteria table, June 1, 2022 to December 31, 2022 Expedited authorization codes and criteria table, December 1, 2021 to May 31, 2022 Expedited authorization codes and criteria table, February 21, 2023 to present Private duty nursing for children billing guide, July 1, 2022 to February 20, 2023 Private duty nursing for children billing guide, October 1, 2020 to June 30, 2022 Private duty nursing for children billing guide, View all private duty nursing for children billing guides, January 1, 2023 to present Private duty nursing fee schedule, January 1, 2020 to December 31, 2022 Private duty nursing fee schedule, July 1, 2016 to December 31, 2019 Private duty nursing fee schedule, April 1, 2023 to present Professional administered drug fee schedule, January 1, 2023 to March 31, 2023 Professional administered drug fee schedule, October 1, 2022 to December 31, 2022 Professional administered drug fee schedule, View all professional administered drugs fee schedules, July 1, 2022 to present Prosthetic and orthotic devices billing guide, April 1, 2022 to June 30, 2022 Prosthetic and orthotic devices billing guide, October 1, 2021 to March 31, 2022 Prosthetic and orthotic devices billing guide, View all prosthetic and orthotics billing guides, July 1, 2022 to present Prosthetic and orthotics fee schedule, October 1, 2021 to June 30, 2022 Prosthetic and orthotics fee schedule, July 1, 2021 to September 30, 2021 Prosthetic and orthotics fee schedule, View all prosthetic and orthotics fee schedules, August 1, 2022 to present Respiratory care billing guide, July 1, 2022 to July 31, 2022 Respiratory care billing guide, October 1, 2021 to June 30, 2022 Respiratory care billing guide, July 1, 2022 to present Respiratory care fee schedule, October 1, 2021 to June 30, 2022 Respiratory care fee schedule, July 1, 2021 to September 30, 2021 Respiratory care fee schedule, April 1, 2023 to present Rural heath clinics billing guide, January 1, 2023 to March 31, 2023 Rural health clinics billing guide, October 1, 2022 to December 31, 2022 Rural health clinics billing guide, April 1, 2023 to present RHC encounter rates, January 1, 2023 to March 31, 2023 RHC encounter rates, October 1, 2022 to December 31, 2022 RHC encounter rates, April 1, 2023 to present RHC enhancement rates, January 1, 2023 to March 31, 2023 RHC enhancement rates, October 1, 2022 to December 31, 2022 RHC enhancement rates, October1, 2022 to present SBHS billing guide, July 1, 2022 to September 30, 2022 SBHS billing guide, October 1, 2021 to June 30, 2022 SBHS billing guide, July 1, 2022 to present SBHS fee schedule, October 1, 2021 to June 30, 2022 SBHS fee schedule, July 1, 2021 to September 30, 2021 SBHS fee schedule, January 1, 2023 to present Sleep centers billing guide, July 1, 2022 to December 31, 2022 Sleep centers billing guide, October 1, 2020 to June 30, 2022 Sleep centers billing guide, April 1, 2023 to present Sleep centers fee schedule, January 1, 2023 to March 31, 2023 Sleep centers fee schedule, July 1, 2022 to December 31, 2022 Sleep centers fee schedule, January 1, 2023 to Present Sterilization billing guide, October 1, 2022 to December 31, 2022 Sterilization billing guide, July 1, 2022 to September 30, 2022 Sterilization supplemental billing guide, Physician-related/Professional Services Billing Guide, Sterilization Consent Form (HHS-687) (English), Sterilization Consent Form (HHS-687) English large print, Sterilization Consent Form (HHS-687-1) (Spanish), Sterilization Consent Form (HHS-687-1) Spanish large print, 1, 2023to present Substance use disorder billing guide, January 1, 2023to March 31, 2023 Substance use disorder billing guide, October 1, 2022 to December 31, 2022 Substance use disorder billing guide, View all SUD (FFS outside BHO process) billing guides, July 1, 2022 to present Substance use disorder fee schedule, October 1, 2021 to June 30, 2022 Substance use disorder fee schedule, January 1, 2021 to September 30, 2021 Substance use disorder fee schedule, View all substance use disorder fee schedules, January 1, 2023 to present Substance-Using Pregnant People (SUPP) Program billing guide, February 26, 2023 to present Telemedicine billing guide, January 1.

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