Payer
| Payer Name |
CMS |
Transaction ID |
333333333 |
Provider
| Provider |
IRNAME |
| Address |
,
|
| Provider ID |
NPI |
Tax ID |
|
Subscriber
| Insured Name |
LNAME, FNAME MNAME |
| Member ID |
HICN |
SSN |
|
| Group Number |
|
Group Name |
|
| Date of Birth |
1920-04-01 |
Gender |
Female |
| Address |
ADDRESS LINE1ADDRESS LINE2 |
|
CITY, SC ZIPCODE |
| Dependent Sequence Number |
1
|
| Branch |
0002 |
| Subdivision |
0001 |
| Employee ID Number |
|
| Plan Code |
|
Coverage Dates
| Dependent Coverage Dates |
|
Eligibility Begin |
Deductibles & Maximums
|
Deductible
|
|
|
|
992 |
|
Family
|
$150.00
|
|
|
0 |
|
Family
|
$150.00
|
|
|
0 |
|
Family
|
$150.00
|
| Individual |
|
|
Family
|
$150.00
|
|
Maximum
|
|
|
Individual
|
|
$2,000.00
|
|
|
Amount Used
|
$103.00
|
|
|
Amount Remaining
|
$1,897.00
|
|
Individual, Dental Care
|
|
$2,000.00
|
|
|
Amount Used
|
$103.00
|
|
|
Amount Remaining
|
$1,897.00
|
|
Individual, Periodontics
|
|
$2,000.00
|
|
|
Amount Used
|
$103.00
|
|
|
Amount Remaining
|
$1,897.00
|
|
Individual, Orthodontics
|
Lifetime
|
$2,500.00
|
Plan Provisions
|
This plan Coordinates Benefits
|
|
This plan uses Birthday Rule to Coordinate Benefits
|
|
COB Type - Non-duplication of benefits applies.
|
|
This plan covers teeth lost prior to the effective date
|
|
Total ortho charge to be considered as the placement charges 20%
|
|
Repetitive ortho payments are made QUARTERLY
|
Coverage
|
Description
|
|
|
Deductible Applies
|
| Medicare Part A |
|
|
NO
|
| Medicare Part B |
|
|
NO
|
Frequency Limitations
|
Procedure
|
Restriction
|
Last Visit
|
|
|
60 Days Remaining |
|
|
|
20 Days Remaining |
|
|
|
43 Days Remaining |
|
|
|
20 Days Remaining |
|
|
|
8 Number of Services or Procedures Remaining |
|
|
|
Remaining |
|
| Physical and Speech Therapy |
Remaining |
|
Age Limitations
|
Plan
|
Procedure
|
Restriction
|
|
|
|
Student To Age 25
|
|
|
|
Dependent To Age 19
|
|
|
Orthodontics
|
Child To Age 19
|
|
|
Orthodontics
|
Student To Age 25
|
|
|
Orthodontics
|
Employee To Age 99
|
|
|
D1204
|
To Age 19
|
|
|
D1510
|
To Age 19
|
|
|
D1351
|
To Age 19
|
Other
|
Employer
|
|
|
Name
|
MY EMPLOYER
|
|
Address
|
|
|
|
|
Payer
|
|
|
Name
|
MetLife
|
|
Address
|
PO BOX 981282
EL PASO, TX 79998
|
|
Contact
|
|
Telephone
|
(888) 660-1046
|
Disclaimer: This eligibility report is for informational purposes
only. The information is derived directly from the payer indicated on the report
and is not to be construed as a guarantee of payment.