Meziel Dennis Morales

DATE: 09/14/2020 Support Team Member: Meziel Dennis REP NAME: Jiho Reference #- Patient Information Notes PATIENT FIRST NAME PATIENT LAST NAME PATIENT DOB SUBSCRIBER FIRST NAME SUBSCRIBER LAST NAME RELATIONSHIP to PATIENT SUBSCRIBER DOB SUBSCRIBER SSN OR ID # GROUP # GROUP/EMPLOYER NAME Insurance Information INSURANCE CARRIER INSURANCE PHONE # INSURANCE ADDRESS INSURANCE PAYOR ID # EPO Plan? WHAT FEE SCHEDULE? IN NETWORK or OUT of NETWORK? EFFECTIVE DATE CALENDAR YEAR OR CONTRACT YEAR: YEARLY MAXIMUM MAXIMUM USED TO DATE IDIVIDUAL DEDUCTIBLE FAMILY DEDUCTIBLE DEDUCTIBLE MET TO DATE DEDUCTIBLE WAIVED ON PREVENTATIVE? PREV included in MAXIMUM? TIMELY FILING Anthem Blue Cross - P.O Box 6199 Indiianppolis IN- NO Anthem Completed IN 02/01/2020 CAL YEAR $2,500.00 $200.00 $50.00 $150.00 NOT MET NO YES 12mths from dos CONTRACT YEAR: RM=$2300.00 RM=$50.00 RM=$150.00 % DIAGNOSTIC/PREVENTATIVE BASIC ENDO PERIO ORAL SURGERY MAJOR FLUORIDE (D1206) Age Limit? Frequency Limitations? SINGLE CROWNS(2740) ONLAYS (D2644) BUILDUP (D2950) IMPLANTS (D6010) SEALANTS (1351) Age Limit? Primary and/or Permanent Teeth Only Frequency Limitations? SDF (D1354) SPACE MAINTAINER (D1510 AND D1516) Age Limit? Frequency Limitations? Resin Infiltration (D2990) Irrigation (D4921) Arestin (D4381) Laser (D7465) 100% 90% 90% 90% 90% 60% pre-estimate/ subject to review 100% 18 and younger 1x/12mths 60% 1x/84mths 60% 1x/84mths 60% 1x/84mths 60% 1x/84mths / FMX and PANO on claim 100% 15 and younger 1st & 2nd unrestored perm molars 1x/24mths 0% NOT COVERED 100% 16 and younger 1x/lifetime 0% NOT COVERED 0% NOT COVERED 0% NOT COVERED 0% NOT COVERED Desensitizer (D9910) ORTHO Ortho maximum Age Limit? ORTHO Payout? FREQUENCIES PROPHY (adult and children) (D1110 adult D1120 Child) D1120 (Child AGE LIMIT) Prophy shares frequency with Perio Maintenance? SCALING & ROOT PLANING (D4341) All quads allowed on same day? INTRA ORAL PHOTO (D0350) BITEWINGS (D0274) PA'S (D0220, D0230 and D0240) FMX/PANO (D0210 and D0330) Do FMX and PANO share frequencies? 3 AND UNDER EXAM (D0145) EXAM (D0120) LIMITED EXAM (D0140) PALLATIVE EXAM (D9110) Do exams share frequencies? FILLINGS (D2391) CROWNS (2740) STAINLESS STEEL CROWN (D2930) 0% NOT COVERED 50% $2,500.00 RM-$2500.00 / NO DEDCUTIBLES NO AGE LMT and younger 3 payment 1 payment willl be made on bonding date and every 6 months after automatic Detail 4x/12mths 14 and under YES 1x/36mths YES NOT COVERED 1x/12mths 4x/12mths 1x/60mths YES 2x/yr 2x/yr 2x/yr NO FREQUENCY NO 1x/24mths 1x/84mths 1x/60mths 100% 60% perio charting & x-ray required 100% 100% 100% 100% 100% shared all exam - 100% 90% 90% 60% 60% Detail NO YES NO NITROUS OXIDE (D9230) EXTRACTION (D7140) ARE PRIOR EXTRACTIONS COVERED? FILLING(D2391) COMPOSITES DOWNGRADED? If yes, add detail CROWNS (D2740) DOWNGRADED? If yes, add detail NITEGUARD COVERAGE? (D9944) WAITING PERIOD? If yes, add detail NO NO NO NO HISTORY: FMX PROPHY PANO EXAM BWX FILLINGS CROWN DATE no hx D4910 - 02/21/2020 no hx 02/21/2020 02/21/2020 no hx no hx 1x/lifetime- 90% 02/01/2020- will be satisfied 02/01/2023