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.