Payer

Payer Name MET LIFE Transaction ID 524233885

Provider

Provider JOHN DAVIDSON
Address  
Provider ID 1987654321 Tax ID  

Subscriber

Patient Name Jane Doe
Member ID 123456789 SSN  
Group Number 5921907 Group Name  
Date of Birth 08/30/1961 Gender Female
Address 123 MAIN STREET
VALHALLA, NY 10595

Coverage Type

Dental: Employee and Spouse, Active Coverage
Group Policy

Coverage Dates

Subscriber Coverage Dates
Policy Effective 10/1/2014
Plan Begin Date 1/1/2017
Plan End 12/31/2017

Deductibles & Maximums

DeductibleIn NetworkOut of Network
Individual$50.00$50.00
Family$150.00$150.00
MaximumIn NetworkOut of Network
Individual, Dental CareAnnual$5,000.00$5,000.00
 Amount Used$181.00$181.00
 Amount Remaining$4,819.00$4,819.00
Individual, PeriodonticsAnnual$5,000.00$5,000.00
 Amount Used$181.00$181.00
 Amount Remaining$4,819.00$4,819.00

Plan Provisions

Waiting Period applies.
Second Molar Sealants - Permanent molars only, excluding wisdom teeth.
First Molar Sealants - Permanent molars only, excluding wisdom teeth.
Prostheses and root canals are billable on Completion Date.
The plan does not cover any porcelain, veneer or titanium materials on molars. The plan benefit is based upon the alternate benefit of a full cast restoration.
The maximums and deductibles for these services may be combined with other types of procedures, such as TMJ or Perio.

Coverage

DescriptionIn NetworkOut of NetworkDeductible AppliesMessage
Diagnostic Dental100%100%  
Routine(Preventive) Dental100%100%  
Restorative80%80%  
Endodontics80%80%  
Periodontics80%80%  
Prosthodontics50%50%  
Oral Surgery80%80%  
Orthodontics0%0%  
D0150100%100%  
D0210100%100%  
D0270100%100%  
D0431   NOT COVERED
D1110100%100%  
D1208100%100%  
D1351100%100%  
D1510100%100%  
D214080%80%YES 
D239180%80%YES 
D263050%50%YES 
D264350%50%YES 
D275050%50%YES 
D291080%80%YES 
D295450%50%YES 
D298080%80%YES 
D331080%80%YES 
D426080%80%YES 
D434180%80%YES 
D438180%80%YES 
D491080%80%YES 
D511050%50%YES 
D567080%80%YES 
D575150%50%YES 
D601050%50%YES 
D601350%50%YES 
D621050%50%YES 
D714080%80%YES 
D724080%80%YES 
D7880   NOT COVERED
D8070   NOT COVERED
D9110100%100%  
D922350%50%YES 
D994050%50%YES 
D9972   NOT COVERED

Frequency Limitations

PlanProcedureRestrictionLast Visit
Out-NetworkD01501 time per 6 Months08/26/2016
 D02101 time per 60 Months08/26/2016
 D02701 time per 12 Months 
 D11101 time per 6 Months08/26/2016
 D12081 time per 12 Months 
 D13511 time per 60 Months 
 D15101 time per 99 Calendar Years 
 D21401 time per 24 Months 
 D23911 time per 24 Months 
 D26301 time per 10 Calendar Years 
 D26431 time per 10 Calendar Years 
 D27501 time per 10 Calendar Years 
 D29101 time per 12 Months 
 D29541 time per 10 Calendar Years 
 D29801 time per 12 Months 
 D33101 time per 99 Calendar Years 
 D42601 time per 36 Months 
 D43411 time per 24 Months 
 D49102 times per 1 Calendar Year 
 D51101 time per 10 Calendar Years 
 D56701 time per 12 Months 
 D60101 time per 10 Calendar Years 
 D60131 time per 10 Calendar Years 
 D62101 time per 10 Calendar Years 
In-NetworkD01501 time per 6 Months08/26/2016
 D02101 time per 60 Months08/26/2016
 D02701 time per 12 Months 
 D11101 time per 6 Months08/26/2016
 D12081 time per 12 Months 
 D13511 time per 60 Months 
 D15101 time per 99 Calendar Years 
 D21401 time per 24 Months 
 D23911 time per 24 Months 
 D26301 time per 10 Calendar Years 
 D26431 time per 10 Calendar Years 
 D27501 time per 10 Calendar Years 
 D29101 time per 12 Months 
 D29541 time per 10 Calendar Years 
 D29801 time per 12 Months 
 D33101 time per 99 Calendar Years 
 D42601 time per 36 Months 
 D43411 time per 24 Months 
 D49102 times per 1 Calendar Year 
 D51101 time per 10 Calendar Years 
 D56701 time per 12 Months 
 D60101 time per 10 Calendar Years 
 D60131 time per 10 Calendar Years 
 D62101 time per 10 Calendar Years 

Age Limitations

PlanProcedureRestriction
Out-NetworkD1208 To Age 14
Out-NetworkD1351 To Age 14
Out-NetworkD1510 To Age 14
In-NetworkD1208 To Age 14
In-NetworkD1351 To Age 14
In-NetworkD1510 To Age 14
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.