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 Type

: ,

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.