In Illinois, DMO plans provide limited out-of-network benefits. Please see your plan documents. Download the Pharmacy Information Authorization form (13-835A). If so, we will confirm which plan has primary responsibility for claim payment. WebPlease note all requested contact information is for the provider * Due to contractual requirements, MetLife is prevented from soliciting certain providers. 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. January 1, 2023 to present Dental program fee schedule (updated January 26, 2023) 0000039476 00000 n
Yes. 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 Top 3 reasons to choose Aetna Dental Your choice of any licensed dentist, in or out of network, worldwide, including virtual providers The Apple Health PDL can be found on the agency's Apple Health PDL page. 4+t?1zxn
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Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. 0000050892 00000 n
No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians. hbbd```b``v> >d(XM|&c0L*e$li6"A@Lg` hT
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By contacting the Payor, a provider can identify which network fee schedule is being utilized for claim reimbursement and verify participation status with the plan. Each covered family member can select their own. In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government. 797 0 obj
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Aetna's conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna). Hn0} %PDF-1.4
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Any use of CPT outside of Aetna Clinical Policy Bulletins (CPBs) should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. &,MJtN-F;+U_t+|\b2*M-r!N66;ZWFl\4)*8jw#W`hps>O"9nblas %$puu$|0,}kd4$p$ap,KU{. License to use CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. YN8e#'gxs4`T=>q{J&e-v%w+lC**hvD(5'-*GK v`
WebDenteMax is one of the largest leasable dental PPO networks in the United States. \-.m\EqYt0.\fj JR
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m-4f'f{">H746Z5apg`u0? Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. endstream
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You can see if your plan has a work-in-progress exclusion. Discontinued 3/31/2013. Find individual dental insurance plans near you with budget-friendly coverage options and get a quote. 0000142900 00000 n
License to sue CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. WebLike most group benefits programs, benefit programs offered by MetLife and its affiliates contain certain exclusions, exceptions, waiting periods, reductions of benefits, limitations 0000038707 00000 n
Use our billing guides and fee schedules to determine if a PA is required and assist in filing claims. Metropolitan Life Insurance Company, New York, NY 10166 Disclaimer of Warranties and Liabilities. You may choose a new one once a month. You can reach them at the number on your ID card. 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. The primary payor pays claims as it normally does. endstream
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In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. L0621014064[exp0622][All States]. 0000037280 00000 n
How do providers identify the correct payer? What you pay will be based on a percentage of those charges (coinsurance). While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. %%EOF
WebAmount of every $100 in premiums used to pay for claims and administration for the year ending Dec. 31, 2017 You can still visit any licensed dentist, but your out-of-pocket costs may be higher if you choose a non-PPO dentist. endstream
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No fee schedules, basic unit, relative values or related listings are included in CPT. WebYou may choose one of four dental plans, offered by SafeGuard, a MetLife Company and Metropolitan Life. Links to various non-Aetna sites are provided for your convenience only. 0000037307 00000 n
How do I notify SEBB that my loved one has passed away? 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). In the event that a member disagrees with a coverage determination, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law. MetLifes Preferred Provider Organization (PPO) plans feature the MetLife Preferred Dentist Program, which is designed to save you money on dental services.1 You can choose from thousands of participating general dentists and specialists nationwide. If so, the primary care doctor will arrange it. Links to various non-Aetna sites are provided for your convenience only. Who can enroll in the plan? A dentist's reimbursement is a combination of: We have an arrangement with our DMO providers. Visit our Forms and publications page to download authorization forms. You can also contact Member Services to determine if they are eligible under your DMO plan. 0000029561 00000 n
Aetna Inc. and its affiliated 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.
WebDental insurance helps you plan for the costs of dental care. Unless required by state law, a pediatric dentist is considered a specialist. Find the one that's right for you. Go to the American Medical Association Web site. Every enrolled family member may select their own primary care dentist. &~gHE}7m3_I<3I$$MYK2([{/)yRX-aE'[;"%[btE*4AwY+B1]B.. HTn0?N$vt.taQ"]QI~}kGvc:PXJ
,DDIuEE}%uDp'QMXzm:h?cZH;%*E[*& Your benefits dont double if you are enrolled in two dental plans.
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. hb``d``c``e`kgg@ ~'a >/*g3,>Ib1h(ettt4@ ceY Orthodontic treatment from a participating provider doesnt require referrals. Spell out street names and abbreviations (State Highway 249 instead of SH 249). See Physician-related/professional services. You can reach them using the number on your ID card. The secondary plan acts like a supplement to the primary plan. "lkBJbQkQ~A~>VKmdCD"*>YF.%Vv]-w0
Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. This search will use the five-tier subtype. Yes, but some plans may limit the benefit to certain teeth. Altamonte Springs dentists Boca Raton dentists Clearwater dentists Coral Gables dentists Coral Springs dentists Daytona Beach dentists Delray Beach dentists Englewood dentists Fort Lauderdale dentists Gainesville dentists Grove City dentists Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider. endstream
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There are several types of coordination of benefits provisions. hbba`b``30 Ga
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Orthodontia (adults and children) You pay 50% of covered services. Vision hardware fee schedule is available through the ESD contract. You may not have coverage to replace teeth that were lost or extracted before your coverage began. Therefore, it is crucial to verify benefits and eligibility with the Payor. For questions about rates or fee schedules, email ProfessionalRates@hca.wa.gov. As a MetLife Vision customer you can access language Applicable FARS/DFARS apply. 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. The ABA Medical Necessity Guidedoes not constitute medical advice. If you are a participating provider with one or more dental benefit plans, you may want to negotiate with those WebMetLifes Table of Maximum Allowable Charges or Fee Schedule applies to dental procedures performed on eligible members participating in MetLifes Preferred Dentist WebProcedure Fees. 4828 0 obj
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WebCleaning for adults is covered every three months. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. 0000086757 00000 n
Before you provide certain services, you will need to submit authorization request forms. 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. If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. It sets what they can charge for covered services. ;^{s4)|I6gPvJ=x Depending on your plan, you may pay for dental care in one of two ways: There are no deductibles or annual dollar maximums. CPT is a registered trademark of the American Medical Association. For other specialists, a referral may be necessary. Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. 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. 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. The responsibility for the content of Aetna Precertification Code Search Tool is with Aetna and no endorsement by the AMA is intended or should be implied. Or contact Member Services for coverage details. Register and log in to your member website. \Jc sVB;xN"#~D=1GE SJ4{[HM`|x>~y\YgO_YQ
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(C8y}H7=s2TiUfS^|d yfGBak44\@j WebYikes, something went terribly wrong!!! WebJuly 1, 2022 to present Mobile anesthesia for dental services billing guide; Fee schedules. $10 to $50 to extract a tooth. 825 0 obj
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If you do not intend to leave our site, close this message. You can reach them at the number on your member ID card. While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. RNa: WebSchedule of Benefits . 0
Your benefits plan determines coverage. Oral surgery You pay 20% of covered services for basic surgery; 50% of covered major surgery. endstream
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After you complete a service, you file claims through the ProviderOne portal. Your and Your 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. For Apple Health clients and clients of the Developmental Disabilities Administration. This page contains billing guides, fee schedules, and additional billing materials to help you submit: Coronavirus (COVID-19) information. Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". Visit our Document submission cover sheets page to find the barcode cover sheets required with additional documentation. endstream
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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). I was billed more than the standard $150 co-payment for a crown. 2023 to February 25, 2023 Telemedicine billing guide, November 2, 2022 to December 31, 2022 Telemedicine billing guide, August 1, 2022 to present Apple Health (Medicaid) physical health audio-only procedure codes, January 1, 2023 to present - Apple Health (Medicaid) audio-only behavioral health codes, August 1, 2022 to December 31, 2022 Apple Health (Medicaid) audio-only behavioral health codes, June 28, 2022 to July 31, 2022 Telehealth services billing guide audio only supplement, May 12, 2023 to present - Clinical policyfor COVID-19, August 1, 2022 to May 11, 2023 Apple Health (Medicaid) clinical policy and billing for COVID-19, July 22, 2022 to July 31, 2022 Apple Health (Medicaid) clinical policy and billing, February 1, 2022 to July 21, 2022 Apple Health (Medicaid) clinical policy and billing, January 1, 2022 to January 31, 2022 Apple Health (Medicaid) clinical policy and billing, View all clinical policy and billing FAQs, June 6, 2020 to December 31, 2021 Apple Health (Medicaid) telemedicine/telehealth brief, May 10, 2020 to June 6, 2020 Apple Health (Medicaid) telemedicine/telehealth brief, April 29, 2020 to May 9, 2020 Apple Health (Medicaid) telemedicine/telehealth brief, May 12, 2023 to present - Apple Health (Medicaid) behavioral health policy and billing, August 1, 2022 to May 11, 2023 Apple Health (Medicaid) behavioral health policy and billing, February 1, 2022 to July 31, 2022 Apple Health (Medicaid) behavioral health policy and billing, April 29, 2021 to January 31, 2022 Apple Health (Medicaid) behavioral health policy and billing, View all behavioral health policy and billing FAQs, July 22, 2022 to present Apple Health (Medicaid) ABA policy and billing, February 1, 2022 to July 21, 2022 Apple Health (Medicaid) ABA policy and billing, January 1, 2022 to January 31, 2022 Apple Health (Medicaid) ABA policy and billing, July 22, 2022 to present Apple Health (Medicaid) FAQ for diabetes education providers, February 1, 2022 to July 21, 2022 Apple Health (Medicaid) FAQ for diabetes education providers, January 1, 2022 to January 31, 2022 Apple Health (Medicaid) FAQ for diabetes education providers, View all FAQs for diabetes education providers, May 3, 2020 to present Apple Health (Medicaid) home health services billing and policy during COVID-19 pandemic, November 20, 2020 to May 2, 2021 Apple Health (Medicaid) home health services billing and policy during COVID-19 pandemic, October 1, 2020 to November 19, 2020 Apple Health (Medicaid) home health services billing and policy during COVID-19 pandemic, View all home health services billing and policy FAQs, July 22, 2022 to present Telehealth requirements for physical, occupational and speech therapy, February 1, 2022 to July 21, 2022 Telehealth requirements for physical, occupational and speech therapy, January 1, 2022 to January 31, 2022 Telehealth requirements for physical, occupational and speech therapy, View all telehealth requirements for physical, occupational, and speech therapy, January 1, 2022 to present Telehealth services in long term care facilities and skilled nursing facilities, May 3, 2021 to December 31, 2021 Telehealth services in long term care facilities and skilled nursing facilities, October 1, 2020 to May 2, 2021 Telehealth services in long term care facilities and skilled nursing facilities, View all Telehealth requirements for LTC and SNF, February 1, 2022 to present Family planning only billing guide telemedicine/telehealth, January 1, 2022 to January 31, 2022 Family planning only billing guide telemedicine/telehealth, May 3, 2021 to December 31, 2021 Family planning only billing guide telemedicine/telehealth, April 1, 2023 to present TransHealth program billing guide, January 1, 2023 to March 31, 2023 TransHealth program billing guide, January 1, 2023 to present TransHealth fee schedule, April 1, 2023 to present Tribal health billing guide, January 1, 2023 to March 31, 2023 Tribal health billing guide, October 1, 2022 to December 31, 2022 Tribal health billing guide, View all Tribal Health Program billing guides, January 1, 2023 to present Tribal health program fee schedule, January 1, 2022 to December 31, 2022 Tribal health program fee schedule, October 1, 2021 to December 31, 2021 Tribal health program fee schedule, July 1, 2022 to present Vision hardware billing guide, January 21, 2022 to June 30, 2022 Vision hardware billing guide, January 1, 2022 to January 20, 2022 Vision hardware billing guide, Guidance for hospitals in billing MCOs for services provided to newborns, January 1, 2023 to present Refer to the. Ho0?4$#UVCr!bf! B[@U=7Y>6.vf 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%. 0000032811 00000 n
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WebYour primary care dentist will provide all of your routine dental care and any copayment or discounted charges will be paid at the time of service If you need a specialty dentist, you may receive a 25 percent discount by using one of the participating specialty dentists from Links to various non-Aetna sites are provided for your convenience only. Employees can choose between an extensive network of dentists and oral care specialists so they find a provider best suited for their needs. As the leading provider of dental benefits and largest commercial carrier, MetLife is committed to helping your employees maximize their benefits. I want information specifically for cy WebBoth of our dental plans include: Comprehensive dental services, from preventive care to crowns, bridges and dentures No in-network deductibles and no waiting periods, including orthodontia for children and adults Worldwide coverage with a large nationwide network. Any languages spoken in offices indicated in this search are self-reported. (For example, if you change your PCD on April 15, the change will take effect May 1. Information is believed to be accurate as of the production date; however, it is subject to change. Discover the best option: HMO, PPO and TakeAlong Dental Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. New and revised codes are added to the CPBs as they are updated. Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change. n[F$6_KZi4k startxref
All agency-contracted managed care organizations (MCOs) and the fee-for-service (FFS) program use the Apple Health PDL. 50% of costs until plan has paid $1,750, then any Members cant choose a pediatric dentist as their PCD. hb```, cb.0800(_^Xf5VtUm]81JRtsFGIGcSPaf@Z F
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)SI{ 0BO|cEs}Oq""TV}c`u-hSwi8J", Check your plan documents or call Member Services for details. You can also view and share your digital ID card from the Aetna Health app. Periodontal maintenance is for patients whove previously had periodontal treatment. How do I notify PEBB that my loved one has passed away? See Access to Baby and Child Dentistry (ABCD). Click home to navigate to home.. Click reset to reset the application.reset to reset the application. 0000050787 00000 n
0000037168 00000 n
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Illinois DMO is not an HMO. WebCoordination of benefits provisions in dental benefits plans are a set of rules that are followed when a patient is covered by more than one dental benefits plan. The five character codes included in the Aetna Clinical Policy Bulletins (CPBs) are obtained from Current Procedural Terminology (CPT), copyright 2015 by the American Medical Association (AMA). Hn@})R$R(8I1$o0Z?IT @m$,RRW$_yV? For previous versions, email us applehealthpharmacypolicy@hca.wa.gov. Benefits provided by SafeGuard Health Plans, Inc., a MetLife company. t|%y,$Z1/7`v||f})"h[sE\o~_z~$q-`?X \h-:tm){1U:;%j%D^TN"pX'nw]Fs3)bNiA@g4,pLk,k{s6?}J}A &\R:lf~>W1C",h+QZ{K'.52 zYtVIp`0 x{B&$M"yhZICt`0>
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2!iMFnAo)1%i"74/+v[0N)mgaJY[X _1d7$3H\3. The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. Use the billing guides and fee schedules to find rate information and the ProviderOne Billing and Resource Guide to walk through the claims process. WebThe sequestration reduction amount for each affected claim will be identified on the explanation of remittance healthcare providers receive from Humana. Verify the spelling of the street name or city. This information is neither an offer of coverage nor medical advice. Do you need a PA form? 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. WebThe Aetna DMO does not have out-of-network coverage; therefore, services received from a provider who is not in the Aetna DMO network will not be covered. Orthodontia. This material is for information only. Unlisted, unspecified and nonspecific codes should be avoided. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt. However, in order to receive maximum benefits, members must select and have care coordinated by a participating primary care dentist. 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. 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.
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