These rules determine WebCan I get an estimate of my out-of-pocket expenses? m-4f'f{">H746Z5apg`u0? endstream endobj 205 0 obj <>/Filter/FlateDecode/Index[17 146]/Length 27/Size 163/Type/XRef/W[1 1 1]>>stream Some problems may need more than one service to fix. It will show you whether a drug is covered or not covered, but the tier information may not be the same as it is for your specific plan. Do you want to continue? Refer to the current Physician-related/professional services for information regarding blood, blood products, and related services. <<5AE96FDB43CC14498BFAFB7B8207E05A>]/Prev 310465/XRefStm 1499>> 0qPWp:dW5 ;6V]BpJ#@DE"?Fo=+57]>>=@^{"p5yM~'A}t`)6ts(T^ `p]~@5zPn/VO=RB;#Gkj@!bg~7s}f You or your dentist may also call Member Services. Therefore, it is crucial to verify benefits and eligibility with the Payor. If you had coverage under a previous insurance carrier, youll have coverage for certain services by that plan even after your Aetna coverage begins. 825 0 obj <>stream n[F$6_KZi4k 0000104077 00000 n 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. In Illinois, DMO plans provide limited out-of-network benefits. {YO2GMP!BJMP(!/(q@>6 0 1 Actual They may differ by plan. WebSchedule of Benefits . Exams are covered every six months (if using a participating dentist, there is a $15 co-payment). Visit our Forms and publications page to download authorization forms. The ABA Medical Necessity Guidedoes not constitute medical advice. 0000016734 00000 n WebProvider Agreement Fee Schedules (Please reference the fee schedule noted in your provider agreement, and if appropriate, check the CMS website to review the fee schedule for Medicaid and Medicare Advantage health plans.) Use our billing guides and fee schedules to determine if a PA is required and assist in filing claims. 0000136999 00000 n Your and Your These services include: We may not cover services youve received without coverage. 50% of costs until plan has paid $1,750, then any Select one of the SafeGuard DHMO Plans or one of the MetLife 206 0 obj <>stream Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in the Clinical Policy Bulletins (CPBs). *Illinois members: State laws vary with regard to out-of-network benefits. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product. You, your employees and agents are authorized to use CPT only as contained in Aetna Clinical Policy Bulletins (CPBs) solely for your own personal use in directly participating in healthcare programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". To find out additional fee information on common procedures in your area, the process is simple When your st dentisuggests treatment, have him or her send a claim form, along with the proposed mtreneatt plans and supporting documentation to MetLife. Direct Referral Dental Plan* MET185A. If so, the primary care doctor will arrange it. ), If you choose a new PCD on the sixteenth day of the month or later, the change will go into effect two months afterward. 0000039476 00000 n Treating providers are solely responsible for medical advice and treatment of members. endstream endobj 4795 0 obj <>stream 0000142900 00000 n endstream endobj 4797 0 obj <>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/Rotate 0/StructParents 0/Type/Page>> endobj 4798 0 obj <>stream How do I notify PEBB that my loved one has passed away? Links to various non-Aetna sites are provided for your convenience only. Any use of CPT outside of Aetna Precertification Code Search Tool should refer to the most Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. endstream endobj 4796 0 obj <>stream Virginia members: In Virginia, DMO is called DNO (Dental Network Only). You may choose a new one once a month. To receive maximum benefits, members must choose a participating primary care dentist to coordinate their care with in-network providers. 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. %PDF-1.7 % hbbd```b``v> >d(XM|&c0L*e$li6"A@Lg` hT The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. They do so as if there is no secondary payor. Call Customer Service at Network dentists are paid contracted fees. 0000032811 00000 n Our clients of insurance companies, third-party administrators and various groups lease the DenteMax PPO network for use in their dental benefit plans in order to service their more than 20 million members nationwide. *v:G)JeU%IcRr)\%Ts6q^HpCw-yAuYxU'`ho(7;v};}%-`Fuak`Htf,i1+S|@n-2yC%\rk&(NV;*_(bH *-y;tKMJE-V4"%!GUTEj)/3R$F`}C f0]o~lb>9=Grn5+;X@:D?CwX}/fb'e[=A3[ ~m;j\ZOE%H8RsZg ~mH.l%:~EYwO-$Hcm6dqaW[dc( z 'u s1 ^ 0000025338 00000 n hW[O8+~ and Section 504 of the Rehabilitation Act of 1973. WebSavings from enrolling in the MetLife Federal Dental Plan will depend on various factors, including the cost of the plan, how often participants visit the dentist and the cost of The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. ;j183 $10 to $50 to extract a tooth. Use the ProviderOne portal to see if a client is eligible for the service and the billing guides and fee schedules to determine if a PA is required. See Physician-related/professional services.). How do I notify SEBB that my loved one has passed away? hbbd```b`` If not, we will pay as the secondary payor. For information related to withdrawal management services (previously detox), please see the agency's inpatient hospital guide. O . WebThe sequestration reduction amount for each affected claim will be identified on the explanation of remittance healthcare providers receive from Humana. MetLife Vision contracted providers allow full and equal How are claims Sign up at BeneFeds.com or call 1-877-888-3337. No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. ?LkG1/p#- -vBw|4W:AB Q=,AfU3mknmwQn%z7 In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. 4828 0 obj <>stream Check your plan documents or call Member Services for details. trailer Click home to navigate to home.. Click reset to reset the application.reset to reset the application. For fee schedule and rate questionsEmail:ProfessionalRates@hca.wa.gov, For all other provider questionsMedical Assistance Customer Service Center (MACSC)Online: secure formPhone: 1-800-562-3022, Website feedback: Tell us how were doing, Copyright 2023 Washington Health Care Authority, I help others apply for & access Apple Health, Apple Health for Workers with Disabilities (HWD), Medically Intensive Children's Program (MICP), Behavioral health services for prenatal, children & young adults, Wraparound with Intensive Services (WISe), Behavioral health services for American Indians & Alaska Natives (AI/AN), Substance use disorder prevention & mental health promotion, Introduction overview for general eligibility, General eligibility requirements that apply to all Apple Health programs, Modified Adjusted Gross Income (MAGI) based programs manual, Long-term services & supports (LTSS) manual, Medical plans & benefits (including vision), Life, home, auto, AD&D, LTD, FSA, & DCAP benefits. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. You are now being directed to CVS Caremark site. You, your employees and agents are authorized to use CPT only as contained in Aetna Precertification Code Search Tool solely for your own personal use in directly participating in health care programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. This applies to services for: For more details, review your plan documents. You can view and print your ID card from your member website. CPT is a registered trademark of the American Medical Association. %PDF-1.4 % The responsibility for the content of Aetna Clinical Policy Bulletins (CPBs) is with Aetna and no endorsement by the AMA is intended or should be implied. Our procedure fee tool provides participants of dental plans insured or administered by MetLife guidance in understanding your dental service providers fees. To change your PCD, log in to your member website. Please be sure to add a 1 before your mobile number, ex: 19876543210, Coinsurance You pay a percentage of covered expenses, Crowns and fixed bridgework when the teeth were prepared before your Aetna coverage began, Appliances (such as dentures) when the impression was taken before your Aetna coverage began, Root canal therapy when the tooth's pulp chamber was opened before your Aetna coverage began. 0000035839 00000 n See Physician-related/professional services. While Clinical Policy Bulletins (CPBs) define Aetna's clinical policy, medical necessity determinations in connection with coverage decisions are made on a case by case basis. Please see your plan documents. WebMetLife's Preferred Dentist Program allows you to select from a network of dentists who have agreed to charge discounted fees. All agency-contracted managed care organizations (MCOs) and the fee-for-service (FFS) program use the Apple Health PDL. Please log in to your secure account to get what you need. \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 Since Clinical Policy Bulletins (CPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies. TmEg=boq1c8-,4%n (x@q U?eVzfK@X^=|?UOeq}:C |zYlK$"91q''o%$D?('N.. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. 20% PPO and out-of-state; 30% non-PPO. However, in order to receive maximum benefits, members must select and have care coordinated by a participating primary care dentist. hb``d``c``e`kgg@ ~'a >/*g3,>Ib1h(ettt4@ ceY Questions may be directed to Humana provider relations by calling 1-800-626-2741, Monday Friday, 8 a.m. 5 p.m., Central time. The DMO plan doesnt have any deductibles or annual maximums. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. All services deemed "never effective" are excluded from coverage. 0 Why? If so, we will confirm which plan has primary responsibility for claim payment. Who can enroll in the plan? Depending on your plan, you may pay for dental care in one of two ways: There are no deductibles or annual dollar maximums. 0000050717 00000 n Signing up is simple and free. You can see if your plan has a work-in-progress exclusion. Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". You can also view and share your digital ID card from the Aetna Health app. The secondary plan acts like a supplement to the primary plan. QyJh6,j9nsm WL Ogf8jN%7}0Q_%uSiz7XtyLs^14(.x Please see your plan documents. endstream endobj 4806 0 obj <>stream How does the plan save me money? 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). This Agreement will terminate upon notice if you violate its terms. While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. %%EOF $10 to $50 to extract a tooth. Oral surgery You pay 20% of covered services for basic surgery; 50% of covered major surgery. %PDF-1.7 % Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna). WebYou may choose one of four dental plans, offered by SafeGuard, a MetLife Company and Metropolitan Life. )SI{ 0BO|cEs}Oq""TV}c`u-hSwi8J", 0000001836 00000 n No fee schedules, basic unit, relative values or related listings are included in CPT. Or call Member Services at the number on your ID card. HMo0?v:JzXc/Y~ 4$8#27t9hkG~NMf]n+tAk Wh._AkJ~Mm1.O]f.ixk% (ABT iE%Jz,3X6#N]W_Q.v(>2(0CH*vy!f( For other specialists, a referral may be necessary. 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). 4792 0 obj <> endobj Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Search for a dentist by name, specialty, ZIP code or the number of miles you are willing to travel. Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. endstream endobj 4805 0 obj <>stream Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. The AMA is a third party beneficiary to this Agreement. _t Or call Member Services for coverage details. It describes the services you have coverage for under your plan. Periodontal maintenance is for patients whove previously had periodontal treatment. If you are a participating provider with one or more dental benefit plans, you may want to negotiate with those Or you can contact Member Services. 0000037280 00000 n However, in order to receive maximum benefits, members must select and have care coordinated by a participating primary care dentist. WebMetLifes Table of Maximum Allowable Charges or Fee Schedule applies to dental procedures performed on eligible members participating in MetLifes Preferred Dentist WebMetLife strongly recommends that you have your dentist submit a pretreatment estimate to MetLife if the cost is expected to exceed $300. 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. Plus, you'll enjoy: More than 400 covered services 2. hb```, cb.0800(_^Xf5VtUm]81JRtsFGIGcSPaf@Z F y'f??XtO?T)c10 i pg*00Ok D & Orthodontia. 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. (Effective October 1, 2015 this guide was merged into the physician-related services/health care professional services billing guide. 0000017206 00000 n Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). G Members should discuss any matters related to their coverage or condition with their treating provider. endstream endobj 4793 0 obj <>/Metadata 104 0 R/Names 4814 0 R/Pages 4786 0 R/Perms/Filter<>/PubSec<>>>/Reference[<>/Type/SigRef>>]/SubFilter/adbe.pkcs7.detached/Type/Sig>>>>/StructTreeRoot 113 0 R/Type/Catalog>> endobj 4794 0 obj <>stream 0000071744 00000 n CPT only Copyright 2022 American Medical Association. By clicking on I Accept, I acknowledge and accept that: The Applied Behavior Analysis (ABA) Medical Necessity Guidehelps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. There are several types of coordination of benefits provisions. Select "Search" to go to the Find a Dentist tool, choose your network and enter your ZIP code for a list of participating dentists. The MetLife dental network includes thousands of providers, so finding the right dentist is easy. Our plans give you the flexibility to visit providers in or out-of-network. 3 Most cleanings and exams are covered 100%. 0000072473 00000 n However, applicable state mandates will take precedence with respect to fully insured plans and self-funded non-ERISA (e.g., government, school boards, church) plans. The member's benefit plan determines coverage. rxo @ e(m#GIByY6Cs|@5'C/9GL[sN`8!@d2j We need to authorize the use of a different provider before treatment. You can reach them at the number on your member ID card. hbba`b``30 Ga Register and log in to your member website. Benefits provided by SafeGuard Health Plans, Inc., a MetLife company. Use the billing guides and fee schedules to find rate information and the ProviderOne Billing and Resource Guide to walk through the claims process. 0000037168 00000 n The discussion, analysis, conclusions and positions reflected in the Clinical Policy Bulletins (CPBs), including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna's opinion and are made without any intent to defame. xref Before you provide certain services, you will need to submit authorization request forms. 0000036990 00000 n Under these circumstances, dental offices may see the need to adjust their fee schedules.

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