If you need more information, contact Member Services. P|!(}!h}qsPq!F#($FikLuJs?nSG^w;jp*B3&x!W x}k}l~'W)+~KZnsN1MVqy G8O,'"Gg Q Log in to your member website first to get personalized results. This comprehensive listing of fee maximums is used to reimburse a physician and/or other providers on a fee-for-service basis. 0000038707 00000 n Unless required by state law, a pediatric dentist is considered a specialist. How are claims endstream endobj 780 0 obj <>/Metadata 30 0 R/Pages 777 0 R/StructTreeRoot 55 0 R/Type/Catalog/ViewerPreferences 798 0 R>> endobj 781 0 obj <>/MediaBox[0 0 612 792]/Parent 777 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 782 0 obj <>stream Choose a primary care dentist who participates in our network. See Physician-related/professional services.). 0000037307 00000 n You can find a network dentist with our online directory. endstream endobj 4805 0 obj <>stream The responsibility for the content of Aetna Precertification Code Search Tool is with Aetna and no endorsement by the AMA is intended or should be implied. This material is for information only. 0000035839 00000 n Network dentists are paid contracted fees. This means if you have two plans that cover two cleanings per year, you dont have four cleanings per year. Applicable FARS/DFARS apply. Members cant choose a pediatric dentist as their PCD. startxref Links to various non-Aetna sites are provided for your convenience only. (For example, if you change your PCD on April 15, the change will take effect May 1. other economic conditions. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. You can see if your plan has a work-in-progress exclusion. 0000020858 00000 n Your benefits dont double if you are enrolled in two dental plans. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. License to use CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. 0 0000038958 00000 n DMO plans require a surgical periodontal history. If so, most services will be considered separately. You can get a Summary of Benefits from your employer that provides your insurance. In the event that a member disagrees with a coverage determination, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law. The DMO plan doesnt have any deductibles or annual maximums. Please see your plan documents. Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider. I was billed more than the standard $150 co-payment for a crown. If so, we will confirm which plan has primary responsibility for claim payment. You can reach them at the number on your member ID card. Questions? Please contact Member Services. WebCan I get an estimate of my out-of-pocket expenses? Verify the spelling of the provider's last name or office name. You must contact us. Signing up is simple and free. G 0000039476 00000 n endstream endobj 4803 0 obj <>stream Direct Referral Dental Plan* MET185A. CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. When billing, you must use the most appropriate code as of the effective date of the submission. Who can enroll in the plan? They do so as if there is no secondary payor. These rules determine Verify the spelling of the street name or city. How do providers identify the correct payer? n[F$6_KZi4k Please see your plan documents. There are several types of coordination of benefits provisions. Some subtypes have five tiers of coverage. Our procedure fee tool provides participants of dental plans insured or administered by MetLife guidance in understanding your dental service providers fees. 0000029561 00000 n Aetna Inc. and itsaffiliated companies are not responsible or liable for the content, accuracy or privacy practices of linked sites, or for products or services described on these sites. 0000113149 00000 n The secondary plan acts like a supplement to the primary plan. While Clinical Policy Bulletins (CPBs) define Aetna's clinical policy, medical necessity determinations in connection with coverage decisions are made on a case by case basis. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. endstream endobj startxref hW[O8+~ WebThe Aetna DMO does not have out-of-network coverage; therefore, services received from a provider who is not in the Aetna DMO network will not be covered. Spell out street names and abbreviations (State Highway 249 instead of SH 249). Reprinted with permission. Aetna Inc. and its affiliated companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites. Links to various non-Aetna sites are provided for your convenience only. *Illinois members: State laws vary with regard to out-of-network benefits. See Physician-related/professional services. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. You or your dentist may also call Member Services. Since Clinical Policy Bulletins (CPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies. <<5AE96FDB43CC14498BFAFB7B8207E05A>]/Prev 310465/XRefStm 1499>> xref Aetna Inc. and itsaffiliated companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites. Yes. WebFind a Dentist. 20% PPO and out-of-state; 30% non-PPO. Treating providers are solely responsible for medical advice and treatment of members. It sets what they can charge for covered services. Life, home, auto, AD&D, LTD, & FSA benefits, Overview of prior authorization (PA), claims & billing, Step-by-step guide for prior authorization (PA), Program benefit packages & scope of services, Community behavioral support (CBHS) services, First Steps (maternity support & infant care), Ground emergency medical transportation (GEMT), Home health care services: electronic visit verification, Substance use disorder (SUD) consent management guidance, Enroll as a health care professional practicing under a group or facility, Enroll as a billing agent or clearinghouse, Find next steps for new Medicaid providers, Washington Prescription Drug Program (WPDP), Governor's Indian Health Advisory Council, Analytics, research & measurement (ARM) data dashboard suite, Foundational Community Supports provider map, Medicaid maternal & child health measures, Washington State All Payer Claims Database (WA-APCD), Personal injury, casualty recoveries & special needs trusts, Information about novel coronavirus (COVID-19), Information about novel coronavirus (COVID-19) webpage, Medical Assistance Customer Service Center (MACSC) online, April 1, 2023 to present ABCD billing guide, October 1, 2022 to March 31, 2023 ABCD billing guide, July 1, 2022 to September 30, 2022 ABCD billing guide, July 1, 2022 to present Acute physical medicine and rehabilitation billing guide, October 1, 2020 to June 30, 2022 Acute physical medicine and rehabilitation billing guide, January 1, 2020 to September 30, 2020 Acute physical medicine and rehabilitation billing guide, View all acute physical medicine and rehabilitation billing guides, July 1, 2022 to present Alien Medical Program billing guide, January 1, 2022 to June 30, 2022 Alien Medical Program billing guide, April 1, 2021 to December 31, 2021 Alien Medical Program billing guide, View all Alien Medical Program emergency assistance billing guides, January 1, 2021 to present Ambulance transportation billing guide, July 1, 2020 to December 31, 2020 Ambulance transportation billing guide, April 1, 2020 to June 30, 2020 Ambulance transportation billing guide, View all Ambulance transportation billing guides, July 1, 2022 to present Ground Emergency Medical Transportation (GEMT) billing guide, October 1, 2020 to June 30, 2022 Ground Emergency Medical Transportation (GEMT) billing guide, January 1, 2020 to September 30, 2020 Ground Emergency Medical Transportation (GEMT) billing guide, July 1, 2021 to present Ambulance transportation, February 29, 2020 to June 30, 2021 Ambulance transportation, July 1, 2019 to February 28, 2020 Ambulance transportation, December 1, 2016 to June 30, 2019 Ambulance transportation, January 1, 2006 to November 30, 2016 Ambulance transportation, July 1, 2022 to present ACS billing guide, July 1, 2021 to June 30, 2022 ASC billing guide, October 1, 2020 to June 30, 2021 ASC billing guide, April 1, 2023 to present -- ASC fee schedule, October 1, 2022 to present March 31, 2023 -- ASC fee schedule, April 1, 2022 to September 30, 2022 ASC fee schedule, October 1, 2021 to March 31, 2022 ASC fee schedule, March 1, 2021 to September 30, 2021 ASC fee schedule, April 24, 2023 to present - ABA billing guide, April 1, 2023 to April 23, 2023 ABA billing guide, January 1, 2023 to March 31, 2023 ABA billing guide, July 1, 2022 to present ABA fee schedule, July 1, 2021 to June 30, 2022 ABA fee schedule, July 1, 2020 to June 30, 2021 ABA fee schedule, ABA COE fee-for-service provider directory, July 1, 2022 to present Blood bank fee schedule, July 1, 2021 to June 30, 2022 Blood bank fee schedule, July 1, 2020 to June 30, 2021 Blood bank fee schedule, View all Blood Bank services fee schedules, Substance-Using Pregnant People (SUPP) program billing guide, January 1, 2022 to December 31, 2022 CUP program billing guide, October 1, 2020 to December 31, 2021 CUP women program billing guide, July 1, 2019 to September 30, 2020 CUP women program billing guide, Inpatient Prospective Payment System (IPPS), October 1, 2020 to present Childbirth education billing guide, April 1, 2019 to September 30, 2020 Childbirth education billing guide, October 1, 2017 to March 31, 2019 Childbirth education billing guide, View all childbirth education billing guides, January 1, 2007 to present Childbirth education, July 1, 2022 to present Chiropractic services billing guide, October 1, 2020 to June 30, 2022 Chiropractic services billing guide, January 1, 2020 to September 30, 2020 Chiropractic services billing guide, View all chiropractic services for children billing guides, July 1, 2022 to present Chiropractic services for children fee schedule, July 1, 2021 to June 30, 2022 Chiropractic services for children fee schedule, July 1, 2020 to June 30, 2021 Chiropractic services for children fee schedule, View all chiropractic services for children fee schedules, April 1, 2023 to present CRT products and services billing guide, July 1, 2022 to March 31, 2023 CRT products and services billing guide, January 1, 2022 to June 30, 2022 CRT products and services billing guide, July 1, 2022 to present CRT fee schedule, April 1, 2022 to June 30, 2022 CRT fee schedule, July 1, 2021 to March 31, 22 CRT fee schedule, October 1, 2022 to present Social services blanket code crosswalk, September 1, 2021 to September 30, 2022 Social services blanket codes, November 17, 2020 to August 31, 2021 Social services blanket codes, July 1, 2022 to present COVID-19 fee schedule, January 1, 2022 to June 30, 2022 COVID-19 fee schedule, July 1, 2021 to December 31, 2021 COVID-19 fee schedule, April 12, 2023 to present - Apple Health COVID-19 vaccine policy, December9, 2022to April 11, 2023 Apple Health COVID-19 vaccine policy, November 21, 2022 to December 8, 2022- Apple Health COVID - 19 vaccine policy, April 24, 2023 to present Apple Health Monoclonal Antibody Treatment COVID-19 clinical policy, December 16, 2022 to April 23, 2023 Apple Health Monoclonal Antibody Treatment COVID-19 clinical policy, September 14, 2022 to December 15, 2022 Apple Health Monoclonal Antibody Treatment COVID-19 clinical policy, August 19, 2022 to September 13, 2022 Apple Health Monoclonal Antibody Treatment COVID-19 clinical policy, May 10, 2022 to August 18, 2022 Apple Health Monoclonal Antibody Treatment COVID-19 clinical policy, April 12, 2022 to May 9, 2022 Apple Health Monoclonal Antibody Treatment COVID-19 clinical policy, March 23, 2022 to April 11, 2022 Apple Health Monoclonal Antibody Treatment COVID-19 clinical policy, View all Monoclonal Antibody Treatment COVID-19 clinical policies, May 12, 2023 to present - Apple Health COVID-19 testing clinical policy, November 21, 2022 to May 11, 2023 Apple Health COVID-19 testing clinical policy, March 4, 2022 to November 20, 2022 Apple Health COVID-19 testing clinical policy, View all COVID-19 testing clinical policies, Access to Baby and Child Dentistry (ABCD), April 1, 2023 to present Dental-related services program billing guide, January 1, 2023 to March 31, 2023 Dental-related services program billing guide, October 1, 2022 to December 31, 2022 Dental-related services program billing guide, July 1, 2022 to present Oral Health Connections pilot project billing guide, January 1, 2022 to June 30, 2022 Oral Health Connections pilot project billing guide, October 1, 2020 to December 31, 2021 Oral Health Connections pilot project billing guide, View all OHC pilot project billing guides, July 1, 2022 to present Mobile anesthesia for dental services billing guide, January 1, 2023 to present Dental program fee schedule, October 1, 2022 to December 31, 2022 Dental program fee schedule, July 1, 2022 to September 30, 2022 Dental program fee schedule, July 1, 2022 to present Diabetes education program billing guide, July 1, 2021 to June 30, 2022 Diabetes education program billing guide, April 1, 2021 to June 30, 2021 Diabetes education program billing guide, View all Diabetes Education Program billing guides, July 1, 2022 to present Diabetes education, July 1, 2021 to June 30, 2022 Diabetes education, July 1, 2020 to June 30, 2021 Diabetes education, View all diabetes education fee schedules, Medical Equipment and Supplies billing guide, January 1, 2019 to March 31, 2019 DME and non-CRT wheelchairs billing guide, October 1, 2018 to December 31, 2018 DME and non-CRT wheelchairs billing guide, July 1, 2018 to September 30, 2018 DME and non-CRT wheelchairs billing guide, Medical Equipment and Supplies fee schedules, January 1, 2019 to March 31, 2019 Other DME fee schedule, January 1, 2019 to March 31, 2019 Wheelchairs and accessories fee schedule, View all DME social services blanket codes, April 1, 2023 to present ESPDT Well-child program billing guide, January 1, 2023 to March 31, 2023 ESPDT program billing guide, July 1, 2022 to December 31, 2022 EPSDT program billing guide, July 1, 2022 to present EPSDT fee schedule, July 1, 2021 to June 30, 2022 EPSDT fee schedule, July 1, 2020 to June 30, 2021 EPSDT fee schedule, March 1, 2023 to present Enteral nutrition billing guide, September 1, 2022 to February 28, 2023 Enteral nutrition billing guide, July 1, 2022 to August 31, 2022 Enteral nutrition billing guide, View all enteral nutrition billing guides, March 1, 2023 to present Enteral nutrition fee schedule, July 1, 2022 to February 28, 2023 Enteral nutrition fee schedule, July 1, 2021 to June 30, 2022 Enteral nutrition fee schedule, January 1, 2023 to present Family planning billing guide, July 1, 2022 to December 31, 2022 Family planning billing guide, February 1, 2022 to June 30, 2022 Family planning billing guide, January 1, 2023 to present Family planning fee schedule, October 1, 2022 to December 31, 2022 Family planning fee schedule, July 1, 2022 to September 30, 2022 Family planning fee schedule, July 1, 2022 to present SRHP fee schedule, October 1, 2021 to June 30, 2022 SRHP fee schedule, Physician-Related Services/Health Care Professional Services Billing Guide, Physician administered drugs fee schedule, Family planning only program telemedicine services offered during the COVID-19 outbreak, Family planning client application (form 13-781), April 1, 2023 to present FQHC billing guide, January 1, 2023 to March 31, 2023 FQHC billing guide, October 1, 2022 to December 31, 2022 FQHC billing guide, April 1, 2023 to present FQHC encounter rates, January 1, 2023to March 31, 2023 FQHC encounter rates, October 1, 2022 to December 31, 2022 FQHC encounter rates, April 1, 2023 to present FQHC enhancement rates, January 1, 2023 to March 31, 2023 FQHC enhancement rates, October 1, 2022 to December 31, 2022 FQHC enhancement rates, August 1, 2022 to present Habilitative services program billing guide, July 1, 2022 to July 31, 2022 Habilitative services program billing guide, January 1, 2022 to June 30, 2022 Habilitative services program billing guide, View all habilitative services billing guides, July 1, 2022 to present Habilitative services, July 1, 2021 to June 30, 2022 Habilitative services, January 1, 2021 to June 30, 2021 Habilitative services, View all habilitative services fee schedules, April 1, 2022 to present Hearing hardware billing guide, November 1, 2020 to March 31, 2022 Hearing hardware billing guide, October 1, 2020 to October 31, 2020 Hearing hardware billing guide, July 1, 2022 to present Hearing hardware fee schedule, April 1, 2022 to June 30, 2022 Hearing hardware fee schedule, July 1, 2021 to March 30, 2022 Hearing hardware fee schedule, April 1, 2022 to present HIV/AIDS case management billing guide, April 1, 2021 to March 31, 2022 HIV/AIDS case management billing guide, October 1, 2020 to March 31, 2021 HIV/AIDS case management billing guide, July 1, 2018 to present HIV/AIDS case management, January 1, 2023 to present Home health (acute care services) billing guide, July 1, 2022 to December 31, 2022 Home health (acute care services) billing guide, April 1, 2022 to June 30, 2022 Home health (acute care services) billing guide, View all home health services billing guides, January 1, 2023 to present Home health fee schedule, July 1, 2022 to December 31, 2022 Home health fee schedule, January 1, 2022 to June 30, 2022 Home health fee schedule, View all home health services fee schedules, January 1, 2023 to present Home Infusion therapy billing guide, November 16, 2022 to December 31, 2022 Home Infusion therapy billing guide, October 1, 2021 to November 15, 2022 Home Infusion therapy billing guide, View all home infusion therapy and nutrition billing guides, January 1, 2023 to present Home infusion therapy/parenteral nutrition fee schedule, October 1, 2022 to December 31, 2022 Home infusion therapy/parenteral nutrition fee schedule, July 1, 2022 to September 30, 2022 Home infusion therapy/parenteral nutrition fee schedule, View all home infusion therapy/parenteral nutrition fee schedules, July 1, 2022 to present Hospice services billing guide, October 1, 2020 to June 30, 2022 Hospice services billing guide, January 1, 2020 to September 30, 2020 Hospice services billing guide, October 1, 2021 to September 30, 2022 Hospice fee schedule, October 1, 2020 to September 30, 2021 Hospice fee schedule, January 1, 2020 to July 1, 2020 Hospital-based inpatient detoxification billing guide, July 1, 2019 to December 31, 2019 Hospital-based inpatient detoxification billing guide, January 1, 2019 to June 30, 2019 Hospital-based inpatient detoxification billing guide, View all hospital-based inpatient detoxification billing guides, January 1, 2023 to present Inpatient hospital services billing guide, October 1, 2022 to December 31, 2022 Inpatient hospital services billing guide, July 1, 2022 to September 30, 2022 Inpatient hospital services billing guide, View all inpatient hospital billing guides, Guidance for billing MCOs for services provided to newborns, RAC Eligibility Codes for Healthy Options Blind/Disabled (HOBD) Clients, November 1, 2022 to present Interpreter services billing guide, April 1, 2022 to October 31, 2022 Interpreter services billing guide, October 1, 2021 to March 31, 2022 Interpreter services billing guide, July 1, 2022 to present Kidney center services billing guide, January 1, 2022 to June 30, 2022 Kidney center services billing guide, January 1, 2021 to December 31, 2021 Kidney center services billing guide, View all kidney center services billing guides, April 1, 2023 to present Kidney centers fee schedule, January 1, 2023 to March 31, 2023 Kidney centers fee schedule, October 1, 2022 to December 31, 2022 Kidney centers fee schedule, View all kidney center services fee schedules, July 1, 2022 to present Long-term care program billing guide, October 1, 2020 to June 30, 2022 Long-term care program billing guide, January 1, 2020 to September 30, 2020 Long-term care program billing guide, View all long-term acute care billing guides, August 1, 2022 to present MSS/ICM billing guide, July 1, 2022 to July 31, 2022 MSS/ICM billing guide, January 1, 2021 to June 30, 2022 MSS/ICM billing guide, July 1, 2020 to present MSS/ICM fee schedule, January 1, 2020 to June 30, 2020 MSS/ICM fee schedule, October 1, 2015 to December 31, 2019 MSS/ICM fee schedule, March 24, 2023 to present Medical Equipment and Supplies Billing Guide, October 21, 2022 to March 23, 2023 Medical Equipment and Supplies Billing Guide, October 1, 2022 to October 20, 2022 Medical Equipment and Supplies Billing Guide, View all Medical equipment and supplies billing guides, April 1, 2023 to present Medical Equipment and Supplies fee schedule, October 1, 2022 to March 31, 2023 Medical Equipment and Supplies fee schedule, July 1, 2022 to September 30, 2022 Medical Equipment and Supplies fee schedule, View all medical equipment and supplies fee schedules, April 1, 2023 to present Medical nutrition therapy billing guide, February 17, 2023 to March 31, 2023 Medical nutrition therapy billing guide, August 1, 2022 to February 16, 2023 Medical nutrition therapy billing guide, View all medical nutrition therapy billing guides, July 1, 2022 to present Medical nutrition therapy fee schedule, July 1, 2021 to June 30, 2022 Medical nutrition therapy fee schedule, July 1, 2020 to June 30, 2021 Medical nutrition therapy fee schedule, View all medical nutrition therapy fee schedules, April 1, 2023 to present - Mental health services billing guide, January 1, 2023 to March 31, 2023 Mental health services billing guide, October 1, 2022 to December 31, 2022 Mental health services billing guide, View all mental health services billing guides, April 1, 2023 to present Mental health and psychology services fee schedule, January 1, 2023 to March 31, 2023 Mental health and psychology services fee schedule, July 1, 2022 to December 31, 2022 Mental health and psychology services fee schedule, View all mental health services fee schedules, January 1, 2023 to present Specialized mental health fee schedule, July 1, 2022 to December 31, 2022 Specialized mental health fee schedule, January 1, 2022 to June 30, 2022 Specialized mental health fee schedule, View all specialized mental health services fee schedules.
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