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 Dates
Dependent Coverage Dates |
Eligibility Begin |
Deductibles & Maximums
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.