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Using out-of-network providers

If you see an out-of-network provider you can still receive a benefit from DMBA. However, your out-of-pocket cost will most likely be higher. Each out-of-network provider may charge a different amount for an office visit, so the amount you pay could be higher than the illustration below. Use a network provider whenever possible!

Sample provider costs

  Network provider Out-of-network provider
Office visit charge $160 $160
Amount paid by DMBA 113 108
Your copayment 20 25
Over maximum allowable amount* (27) 27
Total paid by you $20 $52
* This amount is waived by network providers as part of their contract. For out-of-network providers, you pay this amount.

How to submit a claim

If your out-of-network provider does not submit the claim to DMBA, please do the following.

Step 1

Complete a Medical & Dental Claim Form, found at www.dmba.com/nsc/forms/PDF/M-01.pdf. (You can also find it on www.dmba.com under Forms Library at the bottom of the page.)

Step 2

Attach a copy of the itemized bill you received from your provider. Make sure the form includes the provider’s Tax Identification Number (TIN), diagnosis code(s), procedure code(s), date(s) of service, and charged amounts.

Step 3

Submit the claim form and bill to DMBA by mail, email, or fax.

  • Mail to the address on the form:
    DMBA
    P.O. Box 45530
    Salt Lake City, UT 84145-0530
  • Send a secure email:
    1. Log in to dmba.com.
    2. Click on Contact Us at the bottom of the page.
    3. Click on Send a secure message.
    4. Complete the online fields.
    5. Add the claim form as an attachment.
    6. Click Submit Message.
  • Fax: 801-578-5903