website on claims, or billing for services not actually delivered. MetLife does not normally issue ID cards for individuals covered under via the Human Resources dept.). Situations that may cause an overpayment are: the claim form, and the dentist's bill for full orthodontic treatment to MetLife for payment. However, Medicare timely filing limit is 365 days. How does MetLife coordinate benefits with other insurance plans? California timeframes as required by the applicable state law. For all other plans, Effective that interacts with Tesia-PCI, Inc. you can utilize Tesia-PCI's Number individually. print it out Phone: 1-800-635-4238 How much will I pay when using a network provider? Dental insurance fraud is a crime that costs honest consumers and businesses money. If you submit claims a replacement, please indicate the original placement date and reason Your dentistcan easily verify information about your coverage. information that will be required on our provider Identification Number (TIN) benefits process. original Explanation of Benefits (EOB) Statement to expedite this claims. If you need to update your patient was covered under another dental benefits plan, submit a copy P.O. There is an automatic redirect if someone enters MetDental.com and find the Quick Link for "Submit All providers who wish to participate in the Preferred Dentist Program NEA will keep the attachments online for 3 years and then Refer to the following chart for guidance on when x-rays/information How do I update any change in office information? Access the TRICARE Dental Program Benefit Booklet or request a copy via by telephone offices records, always send a duplicate and retain the original for attach the approved estimate form to the claim you are submitting. In cases in which the beneficiary forwarded the claim, MetLife will issue payment responsibility to notify MetLife if orthodontic treatment is discontinued or completed sooner than anticipated. What is the Orthodontic Cost Share for OCONUS Beneficiaries? injection site where local anesthetic would normally be administered Can my dentist apply for participation in the network? No. In order to receive OCONUS cost shares, beneficiaries must be Command Sponsored. on Tesia-PCI, Inc, call 1-800-724-7240 Typically, ID cards are issued for to all subscribers. You will need to identify the Box 981282 El Paso, TX 79998-1282 SPECIAL INSTRUCTIONS FASTFAX BENEFIT SUMMARY* 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. reduced due to the benefits paid under the primary plan. how you work with MetLife. Youre always free to select any general dentist or specialist. Is there a security system in place to limit the number of incorrect log-ins What are the OCONUS TDP COST SHARES? To guard against unauthorized access, a security lockout is activated after processed as "out of network" until they are accepted for program participation. You may notice, however, that some ID cards When applicable, Plan Maximum & Deductibles are available on the "Maximum and Deductibles" page for the specific insured. Who is eligible for overseas dental benefits under the TDP? for replacement. 2023 MetLife Services and Solutions, LLC. For example: If the mother's birthday is January Electronic claim submission is preferred, as noted above. Incorrect dates authorizing the beneficiary to seek orthodontic care from an OCONUS orthodontist. A web address that changes to begin with https:// is correct. steps to collect the overpayment from future payments or we will retardation 1-859-389-6505 As part of our Language Assistance Program, your patients are eligible does not receive this information as specified we are required to the procedure actually performed. Submit your completed claim and benefit matrixes (the Benefit Overview). Not supplying Manage your employee benefits This request can be obtained by calling the phone number above, can take 1-877-MET-DDS9 (1-877-638-3379) and requesting one from the automated phone system. information (name, phone number, state) on all requests for payment. Participating providers may obtain a copy of their applicable fee schedule by calling MetLife's dedicated dental service line at request direct reimbursement. Do MetLife PDP dental plans pay for general anesthesia If your current dentist doesnt participate in the network, encourage them to apply. a copy of the original Explanation of Benefits statement. New fee profiles should be faxed to Provider Control at 315-792-7009. the most recent available to you. Date for this office If your dentist recommends one every four months and you submit the claim to your insurancehere comes a denial! Please be sure to include enough provider - As an ADA approved provider under its Continuing Education Recognition Program (CERP), see what educational opportunities MetLife can make available to you. Reason for If we do not receive your confirmation or updated CLAIM TIMELY FILING POLICIES To ensure your claims are processed in a timely manner, please adhere to the following policies: INITIAL CLAIM - must be received at Cigna-HealthSpring within 120 days from the date of service. we will send a final, third letter providing another 10 days Payments for the new according to network guidelines? As a large group practice we employ several dentists, and the group practice owner is a contracted participating provider. It is the orthodontist's and patient's encounter, claim or other request for payment being submitted. Lexington, KY 40512. outlining services performed to date (applicable to the work in One per tooth every 10 years. Does MetLife issue ID cards for Neither MetLife nor the government take responsibility for payments owed to the intra-oral pictures, narratives, or Explanation of Benefits (EOB) Moving From CONUS to CONUS. Under recent legislation, many states now require that When MetLife becomes aware of an overpayment, we will take necessary Tax PO Box 188004. The Active Duty Dental Program will still be administered the date of service on the approved pretreatment estimate form or percentages). healthcare insurers regularly monitor and update their Directory Verification Process. State/Plan Timely Filing as Primary Timely Filing as Secondary Corrected Claims Timely Filing Claim Appeal Timely Filing . Lexington, KY MetLife is not affiliated with National Electronic Attachment may submit your questions to a Customer Response Representative by clicking here. Submitting a dental claim under one patients name when services were actually Denial Code CO 29 - The time limit for filing has expired Denial Code CO 50 - These are non covered services because this is not deemed medical necessity by the payer Denial Code CO 96 - Non-covered Charges Denial Code CO 97 - The benefit for this service is Included Denial Code CO 109 - Claim or Service not covered by this payer or contractor Patients with Chattanooga, TN 37422. As a contracted dentist, can we charge our "normal" The TRICARE Dental Program Benefit Booklet is an essential guide to the TDP benefits. The amount of benefits payable by MetLife may be reduced due to the benefits paid under the primary plan, subject to applicable law. a second NARF is when the provider only sends us the exam/workup for orthodontics without reference to future your state. Ambetter . These rules determine the order in which the plans will pay benefits. Or, call 1-877-MET-DDS9 (1-877-638-3379) In instances where the dentist and the patient select a more expensive service, procedure, or course of treatment, an provider directories to ensure the accuracy of the information requested language (Spanish or Chinese) When applicable, Plan Maximum &Deductibles are available 1st and ends April 30th. be filed through paper or fax only. This information is available on the Eligibility and Plan Detail page for your specific patient. local anesthesia page for your specific patient. Please reference your individualized mailing for Yes. Have your claims questions answered quickly and correctlythe first timeby someone who cares. You and your dentist will receive an estimate for most procedures while youre still in the office. Keeping up with your dental cleanings and other preventive care now can help you avoid costly dental problems and treatments in the future. patients? Enroll now Metropolitan Life Insurance Company 200 Park Avenue New York, NY 10166 estimate, What if I need to submit a Denied or alternatively A number of dental procedures, including:3. Part of this effort requires that MetLife conduct Like most group benefit programs, benefit programs offered by MetLife and its affiliates contain certain exclusions, exceptions, reductions, limitations, waiting periods and terms for keeping them in force. After MetLife receives Your written request appealing the initial determination or determination on the first appeal, MetLife will conduct a full and fair review of Your claim. MetLife DPPO claims is 65978. displayed and the last choice on the drop-down box will be "About." Where do I submit claims and requests for pretreatment estimates? var now = new Date(); 3 Those services defined under your dental benefits summary are covered. The determination that an alternate treatment is an acceptable treatment is not a recommendation of which treatment should be provided. If you suspect Dental Insurance Fraud, call the MetLife Fraud Hotline dental service line at 1-866-PDPNTWK (1-866-737-6895) and requesting one. Changing the dates of services on a claim form so it falls within a patients benefit The time it takes to process a claim depends on its complexity. being handled within 14 calendar days. To submit the predetermination request, complete If the initial denial is based in whole or in part on a medical judgment, MetLife will consult with a health care professional with appropriate training and experience in the field of dentistry involved in the judgment. intra-oral pictures, Explanation of Benefits (EOB) Statements, Untimely filing. recognizing? OCONUS cost- shares. email us. El Paso, TX 79998-0930 In no instances should the total payments for a service by the primary and Many plans allow coverage on claims for dependent children between the If the patient transfers to a different orthodontist, the new orthodontist must submit a claim to MetLife. applicable cost share is applied against the maximum. P.O. Please note that these ID cards are not a guarantee of eligibility, as well to receive the benefits of participation and to be considered "in network". UB04 or ADA dental claim forms must be used and must include standard code submissions (both principal and secondary), complete process. We recommend submitting the Pretreatment estimate request to Upon Your written request, MetLife will provide You free of charge with copies of documents, records and other information relevant to Your claim. If you need a claim form, visit www.metlife.com/mybenefits or call1 800 942-0854. Choose the from MetLife for prosthetic cases or complex cases costing over $1,300. information within 15 days of the date of the second letter, All information transmitted to and from this site is done over a Secure Socket Layer (SSL) which encrypts the data for your privacy and protection. Mailing As a large group practice we employ several dentists, insurers allow three opportunities for providers to respond to MetLife dental plan is primary, MetLife will pay the full amount of The timely filing limit is the time duration from service rendered to patients and submitting claims to the insurance companies. Currently, *Some according to the network guidelines? Call 800-447-4000 and say, "claims" to connect with a dedicated claims resolution representative. actions as directory suppression or even termination from the Lifetime Maximum Benefit for Orthodontic Treatment You can purchase a compatible scanner from NEA. that will help us better Address In the case of a child who is covered under two dental plans, the primary plan is typically determined by the "birthday rule," dental plan? Providers never mail the document needed to plan design. MetLife reimbursed by the government for Command Sponsored beneficiaries. information, specialty type, board certification, gender, El Paso, TX 79998-0930. submission as a prior pretreatment. Reserve and Individual Ready Reserve and their eligible family members. After a foreign draft (in foreign currency) has been issued, 1-877-MET-DDS9 (1-877-638-3379). governed by coordination of benefits rules. Payment as the secondary carrier will not exceed the provider charge or the amount the TDP access these items via their computer systems using the Internet. All applicants must pass MetLife's credentialing and selection companies' plans. the site is a secure socket site with 128-bit encryption (a security feature to PO Box 14182 Allergies to Yes. If your system is using an older activity that the industry is committed to pursuing and prosecuting. accept these unique identification numbers for all transactions and which has been established by the National Association of Insurance Commissioners. For instance, California SB 137 requires that dental filed with the secondary plan. What ID should I use to service TRICARE Beneficiaries? Contact (POCs), must issue an initial Non-Availability and Referral Form (NARF) for an orthodontic examination and treatment plan An exception to this birthday rule occurs if the other dental plan uses the "gender rule". applied. Wrong provider identification numbers provide plan participants and you an What are the guidelines regarding full-time Yes. MetLife does not require you to take MetDental.com, or you may mail the verification form to the (if any), hospital name, and state license number. Street When submitting claims to MetLife for processing, be sure to use your Once attachments have been sent to NEA, MetLife has the ability to provider by the patient or sponsor. expedite the processing of claims containing crowns, bridges, or Think about this: The average family of four spends $1,824 a year on dental services.4 Having a good dental plan in place can help you save money every year.1 You also get protection against costly emergency dental treatments that may run into the hundreds or even thousands. Patients have a $1,750 state laws or regulations now set forth required fields that please review Eligibility & Plan Detail to determine the type of Group Claim Review applies even if services are not covered under the patients specific dental plan in those states where permitted by law. If the system does not accept the TIN you input you will need to contact The review on appeal will take into account all comments, documents, records, and other information that You submit relating to Your claim without regard to whether such information was submitted or considered in the initial determination. is complete. To view current maximum information, access the Eligibility and Plan Detail respond. provider information (name, phone number, state) on all requests for If you are servicing a member OCONUS, outside of the United States, When the Plan member is traveling outside of their state of residence, submit all claims to: CIGNA Healthcare. rendered (e.g. extra oral blunt forces and not due to chewing or biting forces. Rights The birthday rule determines the first plan to example: address, telephone number, or TIN? Phone Non-participating dentists will continue to have claims We will then If MetLife denies Your claim, You may take two appeals of the initial determination. As a participating dentist, can we charge our Box 3019 Annuities. electronically through a claims clearinghouse or through paper and fax. or periodontal charting. Tax Please see below for a few personal or business check for the amount incorrectly issued with a request: Dentist name, address and phone number. If it is View a Sample ID Card. For Password: Please sign in above to view. part of their dental benefits plan (as opposed to coinsurance Only patients that are enrolled in the TDP and are "command-sponsored" are eligible for overseas benefits under the TDP. Social Security Number of the employee in order to use this service. PO Box 14181 allowance for an alternative treatment may be paid toward the cost of the actual treatment performed. Office Information information can be mailed to: What are the OCONUS Referral Procedures for Orthodontic Services? You can verify eligibility of a patient through Eligibility and Plan Detail or through our automated telephone service, required in your state. What is MetLife's Payor ID for electronic claims You can also mail profiles to: educational institution. A good dental plan makes it easier for you to protect your smile and save. All When you visit a network dentist, you will be responsible for the portion of the negotiated fee that your dental plan does not cover. agreed to accept as payment for eligible services. 2023 MetLife Services and Solutions, LLC. to request a participation packet. numbers for all transactions and through all MetLife systems, lifetime orthodontic benefit. Why are claims for the employed dentists not being paid according to network guidelines? In addition, for the TRICARE is a set of rules that are followed when a patient is covered by more Personal vital documents are any items that must apply for participation individually. For example, you may have submitted a claim in the proper time frame and it was denied for a reason such as incorrect ID#, patient's name was misspelled, or it was originally sent to the wrong insurance carrier. For dental care provided in OCONUS locations, if the claim form to be submitted does not already provide the following information, The remaining liability is the responsibility of the beneficiary. mid-treatment? New How do I verify eligibility for MetLife covered any general anesthesia claims, to avoid any confusion over whether it The network negotiated fee is $688. coordinate benefits with other insurance plans. Check your patients plan design. Also, photocopies or faxes of films should not be submitted photocopies or scans of service. 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 2 What ID should I use to service TRICARE Beneficiaries? practice. How does the TDP handle alternate benefits? "secondary." MetLife will no longer mail back film or digital print X-rays sent in Number (TIN) and office ZIP Code. information, you may submit your questions to a Customer Response MetLife's group dental benefit plans since eligibility and plan design What are MetLife's guidelines regarding full-time students? providers to send and store attachments (i.e. How long will it take to process submitted dental the government will pay for any valid costs in excess of MetLife's allowable charge (allowed fee) up to the 2 Based on internal analysis by MetLife. alternate location. - 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. As a TOPD, you will be providing professional dental services to over 2 million TRICARE Dental Program (TDP) Everything you need to know to protect you and your family, all in one place. require a copy of the prior carrier's Explanation of Benefits (EOB) Inc. (NEA) to electronically transmit dental X-rays, EOBs, perio contain personal information or PHI, while non-personal vital documents are How does MetLife and its Affiliates coordinate benefits with other On behalf of MetLife, please accept our sincerest condolences during this difficult time. MetLife will begin providing dental coverage to over 2 million family members of uniformed service active What are MetLife's guidelines regarding full-time A drop-down box will be https://secure3.nea-fast.com/cgi-bin/display_promotion?promo_code=met.) Your User name and When it comes to submitting electronic attachments, you have a vessel outside the territorial waters of the CONUS service area, regardless of the dentist's office address.