Frequently asked questions dental insurance what is the. Please refer to your booklet for a description of covered services. The following informational fields changed or were added to the 2012 ada dental claim form. As of january 1, 2014, paper submitters must use the new claim form. None high low employee information last name first name m. Drug bills must include the name of the medicine submitting a claim please mail, fax, or email a signed, completed claim form with itemized bills and receipts to. Use this form to authorize someone else to access your information in order to help you manage your dental andor vision benefits. Box 14593, lexington, ky 405124593 employee name last, first, middle social security number customer number division class your home address city state zip sex mf date of birth marital status single married your occupation employer name worksite.
Dental claim forms library united concordia dental. Start here choose a product or service from the menu on. Bhemta metlife dental insurance enrollmentchange form. Illinois law child health examination code, 77 ill.
Specialty referral claim form pdf bring this to your general dentist to. Ncflex dental insurance documents nc office of human resources. Predetermination of benefits if total charges for this claim are to exceed the minimum predetermination dollar amount. There are often deductibles, maximum annual coverage, and waiting periods. Enrollment form metropolitan life insurance company for group. Gef091 dec page 3 of 3 efxdp251snw 0111 declarations and signature by signing below, i acknowledge. I confirm that i give consent within the provisions of the data protection act 1998 for unum dental andor its agents to process my personal.
We were not given payment for lab expenses incurred after using a qualified oral surgent on their list. Member dental claim form header information insurance companydental benefit plan information other coverage mark applicable box and complete 511. Phishing is a fraudulent attempt to obtain an individuals personal information, often through a misleading email, text or other online communication. Unum dental, ibex house, minories, london ec3n 1dy 1 2 3.
Metropolitan life insurance company dental expense claim. An online, easy to use, interactive program designed to help you understand your risk for oral disease and your current dental health status, with the goal of helping you improve your oral health. This schedule of benefits is attached to and made a part of the policy. If you have questions about your dental insurance, please contact your companys benefits administrator. Metlife offers you a choice of two different plans.
This form is used to file a claim with metlife dental for expenses or for your dentist to file to receive payment. Your home billing address, phone numbers home, work, cell, allergies, medications and dental insurance plan information. Enrollment form for group insurance metropolitan life insurance company sbc administration p. Consolidated omnibus budget reconciliation act cobra my covered dependents and i are covered by another medical andor dental plan. Page 3 of 5 jy0333federal 1118 fsf dentists pretreatment estimate statement of actual services be sure to sign below. I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan, unless prohibited by law, or the treating dentist or. Member dental claim form header information insurance company dental benefit plan information other coverage mark applicable box and complete 511. Please complete this form using block capitals and black ink. Aetna dental works with claimconnect tm offered by edi health group ehg to provide easy access to check patient eligibility, file a claim, check claim status, view patient rosters and electronic remittance advice. Services or supplies received by you before your dental insurance starts. Enrollment change form group customer information to be. We were never given an information card regarding our id number nor a list of acceptable places to go to for cancer screening labs. Studies show that those with dental coverage are more likely to visit the dentist1.
Box 14091 lexington, ky 405124091 to be completed by employee 1. Dental expense claim form ii new york university please read instructions on reverse side before completing this form to be completed by employee. Get valuable and affordable dental protection for you and your family today through the metlife dental insurance plan for afsa members. Secureone plans dental network is one of the largest in the state. Standard dental claim form canadian dental association. Established in 1987, secureone plan, by securecare dental, is a discount dental plan for individuals and families. Information is derived from several recognized sources, such as the american dental association, the american academy of periodontology and the national institute of dental and craniofacial research. Item 8 employee social security id number must be completedfor the claim to be processed. Heres the metlife dental insurance plan information you. Relationship to employee m self m spouse m child m other 3. Aetna dental po box 14094 lexington, ky 405124094 to be completed by employee use black ink only.
Submit your claim to us by post, email or online using the details below. Metropolitan life insurance company, new york, ny enrollment. Covered service means a dental service used to treat your or your dependents dental condition which is. The standard plan is a low cost plan that is designed for those individuals who primarily would need only diagnostic and preventive dental services. For a low monthly fee, you gain access to a number of highend features that are available through the bigger companies. If the metlife dental benefit plan is primary, metlife will pay the full amount of benefits that would normally be available under the plan, subject to applicable law. The completed claim form should be sent to metlife prior to the commencement of the course of treatment. Dental claim form for personal health insurance approved by the canadian dental association sun life assurance company of canada, a member of the sun life financial group of companies, is committed to keeping your information confidential. Please refer to the enclosures for more information including costs, exclusions, limitations, benefit reductions and terms of coverage. Services for which you would not be required to pay in the absence of dental insurance.
Classic pdp plan dental benefits for you and your dependents. The following when charged by the dentist on a separate basis. Worldwide benefits 600 king street wilmington, delaware 19801 u. I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan, unless the treating dentist or dental practice has a. Detach and mail the completed dental expense claim form to. The metlife dental plans are the traditional indemnity insurance plan whereby you and your family may select the dentist of your choice. Dental services arising out of accidental injury to the teeth and supporting.
Dental coverage is subject to specific limitations and exclusions. Negotiated fees refers to the fees that innetwork dentists have agreed to accept as payment in full for covered services, subject to any copayments. In either case, a statement of benefits paid will be sent to you. Complete and return the enclosed enrollment form right away. For a low annual membership fee, secureone plan provides you with preferred prices on a wide range of dental services. Dental plan benefit option 1 dental plan benefit option 2 metlifes negotiated or pdp fees refer to the fees that dentists participating in metlifes preferred dentist program pdp have agreed to accept as payment in full, for services rendered by them. Dental plans delta dental pposm 17228 deltacare usa hmo 76992 for ca 00001 or parts of nv only 00003. National dental plan limited is authorised and regulated by the financial conduct authority. Dental plan benefit option 2 national affinity services. Individual dental insurance policy schedule of benefits ppo14 this schedule of benefitslists the services available under, as well as cothe policyinsurance percentages, deductibles, maximum benefit amounts, frequency limitations, and exclusions.
If you wish benefits to be paid directly to yourself, do not complete item 22. I have read this enrollment form and declare that all information i have given is true and complete to the best of my knowledge and belief. I declare that the information provided on this form is, to the best of my knowledge, true and complete and authorise unum dental to obtain any information relating to this claim from my dentist. Employee request for best life dental new enrollment add dependents name change address change phone. Keeping your personal information secure is a top priority of metlife. Dental claim form we recommend that you bring a claim form with you when you visit your dentist for an appointment. Complete your section of the claim form items 1 through 21 in full to assure positive identification and prompt payment. Comprehensive ada dental claim form completion instructions. Unum dental is a trading name of national dental plan ltd. And of course staying on top of your care is the key to preventing costly problems that can add up. However, as dental insurance becomes increasingly complex, we can never guarantee what your insurance company will pay for your treatment. You can arrange for metlife to make payment directly to the dentist by completing item 22.
Most dental plans administered by metlife pay benefits for restorative, prosthetic, periodontal or surgical services only when there is evidence of dental necessity as validated by the submitted clinical documentation associated with the claim or preestimate. These rules determine the order in which the plans will pay benefits. Forms for brighthouse life insurance company previously metlife insurance company usa, brighthouse life insurance company of new york previously first metlife investors insurance company, and new england life insurance company can be found at the brighthouse financial eforms site. Copy of benefitinsurance card with effective date medicare supplement plan information showing comprehensive dental coverage authorization i wish to cancel the policy listed above held through the city of virginia beachvirginia beach city public schools. If you receive metlife dental insurance benefits through your employer, you can view and manage them online. Please give all dental insurance cards to receptionist so that copies can be made. Enrollment form metropolitan life insurance company for. Complete this form to receive reimbursement or to pay directly to the dental provider. You are now leaving the aetna dental web site and linking to claimconnect. Plus, going to the dentist regularly can help prevent problems that have been linked to diabetes or heart.