Claim Forms
When you need medical or dental care, it’s best to use in-network providers. You’ll receive the discounted rate and your provider files your insurance claim paperwork on your behalf. For care that is out-of-network, you have the option to submit the claim yourself.
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MEDICAL
When you use an out-of-network provider, you’ll need to submit the claim to insurance yourself. Meritain will reimburse your out-of-pocket expense once you meet your out-of-network deductible. This is separate from an in-network deductible. Meritain will apply their usual and customary portion of your claim to your deductible. Once the deductible is met, they will pay 50% of their usual and customary rate. You’ll be responsible to pay the balance bill. This amount is the difference between the provider’s bill and the usual and customary amount.
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Click here to download a Meritain claim form. Follow the instructions on the form to complete it and mail it to the appropriate address.
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DENTAL
Since we offer two dental plans - DHMO DeltaCare Plan and PPO Delta Dental Plan - the process is different for each.
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Under the DHMO plan, there is no out-of-network coverage. You must use the DeltaCare primary dentist which you elected when you signed up for the plan. If you wish to change your dentist, you must call Delta Dental to do so (1-800-932-0783).
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Under the PPO plan, you may submit a claim form when your dental provider is out-of-network and is not submitting the claim on your behalf. Click here to download a Delta Dental claim form. Follow the instructions on the form to complete it and mail it to the appropriate address.
VISION
Your medical plan includes a vision reimbursement benefit of an exam and up to $100 for materials at the provider of your choice. To receive the reimbursement for your exam and materials, please fill out this form and mail it to Meritain using the address on the form.
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