Q. When must claims be filed?
A. All dental claims must be filed within two years from the date services were received. Before filing a dental claim, consider whether the expense may be covered under your medical plan. Be sure to read the information in the Medical claims for dental work section below.
Aetna Dental PPO Network providers should file all claims directly with Aetna.
Claims for non-network provider care
The Plan has contracted with Aetna to process claims (see Information sources at the front of this SPD for the address and telephone number).
Before visiting a dentist who is not in the Aetna Dental PPO network, obtain a claim form from Aetna, or Employee Connect, or ExxonMobil Family websites for yourself and/or each eligible family member having work done. Fill out the form with personal data about yourself or your family member. Give the form to the dentist. In many cases, the dentist will file the claim for you. If the dentist returns the form to you, send it and the dentist's itemized bill to Aetna. Keep a copy of the completed form for your records.
Keep these facts in mind when using a non-network provider:
- Most dentists expect payment in full for services at the time the work is done.
- When you file a claim form, benefits will be sent to you unless you specifically indicate that Aetna should pay the dentist directly.
In order to be reimbursed under the Plan, claims must be received by Aetna within two years from the date the expense was incurred. It is the participant's responsibility to ensure that claims are filed in a timely manner. If you or your dental provider submits claims past the claim filing deadline, those claims will not be covered by the Plan. You will be responsible for payment.
Explanation of benefits
Aetna will send you an explanation of benefits (EOB) for each claim. The EOB will show what service was performed, how much the dentist charged, and what the covered charge is under the Plan. It shows if a deductible or coinsurance was involved as well as the calculation used to determine your benefit. If payment is not assigned to the provider the EOB for the claim will only be sent to the participant; requests for any additional information needed to resolve the claim will go to participant only.
Claim denial and reconsideration
If all or part of a claim is denied, Aetna will provide you with a written explanation, including the reason for the denial. See the Administrative and ERISA information section in this SPD.
Claims outside the United States
To receive dental care when traveling or working outside the United States, generally you must pay the dental bills first. For reimbursement, submit a claim form and an itemized bill that includes a copy of the tooth chart clearly identifying the tooth number(s) and copies of the diagnostic dental x-rays, periodontal charting and narrative as appropriate. Indicate if the provider is using a USA standard tooth number or a different tooth identification standard. If the original bills are in a foreign language, you should obtain an English translation, if possible, of the services rendered.
Bills should be submitted in the appropriate foreign currency. The claims administrator (Aetna) will convert the bill to U.S. dollars as of the date of service using the currency converter website Oanda at www.oanda.com.
Right of reimbursement and subrogation
If your claim results from an accident or other injury that may be the fault of another party, the Plan will be subrogated to your (or your covered family member's) right of recovery against any party. In addition, you must reimburse any amount paid by the Plan that you recover from any responsible party. The Plan does not require reimbursement from any voluntary medical payments coverage you may carry under your motor vehicle or homeowner's insurance. The Plan will seek reimbursement/ subrogation from coverage you may carry for uninsured/underinsured motorists. The Plan's right to subrogation and reimbursement also constitute an equitable lien against any payments by any responsible party made or payable to you, your covered family members, or anyone acting on your behalf, now or in the future, regardless of how the payments are characterized. For example, injury, illness or disability related payments that you receive for expenses such as past medical expenses, future medical expenses, attorneys' fees and expenses, or other costs or compensation, up to the full amount of all benefits paid by the Plan, must first be used to repay the Plan before any money goes to you. This creates a priority recovery right in favor of the Plan and is not subject to any application of a make-whole or common fund rule under local or other law. By accepting benefits from the Plan you are agreeing to this arrangement. The Plan's right to do this is called its right to impose an equitable lien or constructive trust.
You are required to promptly notify the Plan of any occurrence that may give rise to the Plan's reimbursement/subrogation rights and to cooperate with the Plan (or its representative) to secure these rights. Please refer to the Plan's master documents for additional information on the Plan's reimbursement/subrogation rights.
Coordination of benefits
If you are covered by more than one group dental plan, you are entitled to coverage from all plans in which you participate, but not to the extent that you collect more than 100% of the amount of the allowable charges. However, if you or a family member are covered under an individual plan, the coordination of benefits provision does not apply.
One of the plans covering you is considered the primary plan. Claims must be filed first with the primary plan. After the primary plan pays, file the claim with the secondary plan, including a copy of the bills and an explanation of benefits including the amount paid by the primary plan.Example:
If you, as an employee, are covered by this Plan, then this Plan is primary for you. If your spouse is covered by another dental plan and you are covered under that plan, then your spouse's plan is secondary for you. Also, if your spouse is covered by their employer's dental plan and this Plan, his or her plan is primary and this Plan is secondary.
This Plan is primary for retirees who are not working, regardless of other coverage under a spouse's plan.
The primary plan always pays benefits first, without considering the other plan. The secondary plan then pays based on its provisions — up to the total allowable expenses covered by that plan or up to the total of all covered expenses.
Coverage of a child
When a child is covered under both parents' plans, the birthday rule is used; the plan of the parent whose birthday occurs earlier in the year is the primary plan. The other parent's plan is secondary. If both parents have the same birthday or your spouse's plan has not adopted the birthday rule, the ExxonMobil Dental Plan will consider the plan which has covered the child longer as primary.
There are special rules for children of divorced or separated parents. Unless specifically ordered otherwise by a court decree, the plan of the parent with custody, if he or she has not remarried, is primary and the plan of the non-custodial parent is secondary. If the parent with custody remarries, that parent's plan is primary, the stepparent's plan is secondary and the plan of the non-custodial parent is last.
Retirees covered by two plans
If a retiree covered by the Dental Plan obtains a full-time job in which the retiree is covered by the new employer's dental plan, that plan becomes the primary plan and the Dental Plan is secondary.
When the retiree leaves the last employer, the plan in which the retiree was covered for the longer period becomes the primary plan and the other plan is secondary.
If payment for covered dental expenses should have been made under this Plan, but has been made under any other plan, any insurance company or other organization may be reimbursed an amount the Administrator-Benefits determines will satisfy the intent of coordination of benefits provisions. That amount will be considered to be benefits paid under this Plan and shall fully discharge any obligation to make such payments.
Medical claims for dental work
Some medical plans cover certain dental procedures by a dentist or oral surgeon. Dental procedures that may be covered by your medical plan include:
- Drugs prescribed by your dentist (would be covered by your prescription plan).
- Treatment of fractures or dislocations of the jaw.
- Treatment of teeth and surrounding tissue damaged due to an injury sustained while covered by the Plan. If an accident occurs, claims may be payable as medical expenses, but claims are not coordinated with the ExxonMobil Dental Plan.
For information on which procedures performed by a dentist or oral surgeon may be considered to be medical in nature, contact Aetna Member Services.
After all the medical plans have responded, submit a dental claim form with the medical EOB form(s) explaining the determination of benefits under the medical plan(s), along with a copy of your bill, to Aetna.
If you are an employee who participates in the ExxonMobil Pre-Tax Spending Plan Health Care Flexible Spending Account (HCFSA), Aetna will automatically process any eligible expenses remaining from your dental claim and send you the spending account reimbursement, if you have elected HCFSA automatic reimbursement. This means that, in most cases, you will not need to file a separate pre-tax claim form.