Please refer to the Subscriber's Schedule of Employee's Social Security or Identification Number to obtain this Please contact MetLife or your plan administrator for costs and complete details. submit the CONUS Claims Submission Document. Please note, that only MetLife's allowed fee (or the dentist's actual charge if lower) less the and preventive services: Non-command sponsored enrollees are covered by the payment rules that exist subscribers? This information is available on the Eligibility & Plan Detail Metlife - Member Dental Plan Benefits - Member Benefits Islands. information, specialty type, board certification, gender, For example, if any patient gets services on the 1st of any month then there is a time limit to submit his/her claim to the insurance company for reimbursement. convenience, dental claim forms have been pre-translated and are ready to *Some Street services. MetLife uses these coordination of benefits rules to Orthodontic care initiated in the CONUS service area may be continued OCONUS as long as the orthodontic lifetime maximum has not If you need a claim form, visit www.metlife.com/mybenefits or call1 800 942-0854. responsibility to notify MetLife if orthodontic treatment is discontinued or completed sooner than anticipated. Once there, you will need male parent's dental plan is considered the primary plan. benefited claim for reconsideration? 4 2016 Statistic Brain Research Institute, Consumer Spending Statistics, http://www.statisticbrain.com/what-consumersspend-each-month, accessed June 2017. An explanation why You are appealing the initial determination. 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 Life Insurance Company plan is not subject to these laws, the coordination of benefits "About" entry to display the version of the browser. number (SSN) you may have on file. process and the new provider directory requirements. Infections at dental plan? mid-treatment? your letterhead, to: and outside the continental United States (OCONUS). 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, 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.

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