- Claims for Non-Network Provider Care
- Explanation of Benefits
- Claim Denial and Reconsideration
- Claims Outside the United States
- Right of Reimbursement and Subrogation
- Coordination of Benefits
- Coverage of a Child
- Retirees Covered by Two Plans
- Medical Claims for Dental Work
Before filing a dental claim, consider whether the expense may be covered under your medical plan. Be sure to read the information under the heading Medical Claims for Dental Work on page 32.
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 ExxonMobil Me, or ExxonMobil Family Web sites 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:
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 may be responsible for payment.
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 co-payment was involved as well as the calculation used to determine your benefit.
You can view your EOBs online by signing up for Aetna NavigatorTM. Just go to the Aetna Navigator Web site at www.AetnaNavigator.com and follow the instructions.
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.
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 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.
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.
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.
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.
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.
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.
Medicare as Primary
Some medical plans cover certain dental procedures by a dentist or oral surgeon. Dental procedures that may be covered by your medical plan include:
For information on which procedures performed by a dentist or oral surgeon may be considered to be medical in nature, please review the oral surgery grid on page 54 or contact Aetna Member Services.
If you incur such charges, file your claim for medical benefits first. If more than one group medical plan is involved, make sure you have submitted the claim to every group medical plan before submitting for dental claim processing.
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.
This process enables you to maximize all benefits available to you under your medical plan(s) and the ExxonMobil Dental Plan.
If you participate in the ExxonMobil Medical Plan POS II option, you do not need to file again with the ExxonMobil Dental Plan. Your claim will be processed with no further action required on your part. If you participate in the EMMP Aetna Select option or the EMMSP, your claim needs to be filed with the dental plan rather than the medical plan.
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.