Payer

Payer Name ABC COMPANY Transaction ID 4322

Provider

Provider BONE AND JOINT CLINIC
Address
,
Provider ID Tax ID

Subscriber

Insured Name SMITH, JOHN
Member ID 123456789 SSN
Group Number Group Name  
Date of Birth 1963-05-19 Gender Male
Address 15197 BROADWAY AVENUEAPT 215
KANSAS CITY, MO 64108
Dependent Sequence Number 1
Branch 0002
Subdivision 0001
Employee ID Number  
Plan Code

Dependent

Patient Name SMITH, MARY
Relationship Child SSN
Group Number Group Name  
Date of Birth 1998-10-14 Gender Female
Address 15197 BROADWAY AVENUEAPT 215
KANSAS CITY, MO 64108

Coverage Type

: ,

Coverage Dates

Dependent Coverage Dates
Eligibility Begin

Deductibles & Maximums

Deductible  
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
NO
Medical Care
Chiropractic
Dental Care
Hospital
Emergency Services
Pharmacy
Professional (Physician) Visit - Office
Vision (Optometry)
Mental Health
Urgent Care
NO

Frequency Limitations

Procedure Restriction Last Visit

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.