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Please Review Before Submitting a Claim (Instructions
apply to claim form, not appeal form)
Information for Member (Employee on this form)
- Complete your section of the claim form (items 1 through 21) in full to ensure positive identification
and prompt payment. Please print or type. Note that item 8 (employee social security number) must be completed for the claim to be processed.
- By signing item 20 the patient (or parent or other authorized representative) consents to the use and disclosure of information relating to the services provided by the dentist
or health care professional for the purpose of treatment, payment or health care operation, including submission of a claim for dental benefits to a provider or administrator of dental benefit plans.
This consent will be valid for as long as the patient is entitled to coverage under a dental plan. You are entitled to a copy of this consent. This consent may be revoked in writing delivered
to your dentist or health care professional, but such revocation will not affect any action taken in reliance on this consent prior to revocation. Upon receipt of revocation
or refusal to sign a consent, your dentist or health care provider may decline to provide or continue treatment. If this consent is signed by the authorized representative of the patient, the relationship of the authorized representative must be provided in item 20.
The patient (or parent
if patient is a minor) must sign item 20.
- You must sign the claim form in item 21.
- You can arrange for MetLife to make payment directly to the dentist by completing
item 22. If you wish benefits to be paid directly to yourself, do not complete item 22.In either case, a statement of benefits paid will be
sent to you; you will only receive an EOB after assigning benefits to your dentist if you owe money.
- If total charges for the
planned course of treatment are expected to be $300 or more,
the form should be completed and submitted to MetLife
prior to the commencement of the course of treatment
for a pretreatment estimate of benefits. MetLife will
notify you of your benefits payable. (If you wish, a pretreatment
estimate may be requested for anticipated dental expenses
of less than $300.)
- If total charges for the
planned course of treatment will be less than $300, the
claim form should be completed when treatment is completed
and mailed to the address shown below. Dental coverage is
subject to specific limitations and exclusions. Please refer
to your Union Benefits Trust
plan handbook for a description of covered services,
schedule of benefits payable, limitations and exclusions.
Information for Attending Dentist
- Benefits are payable in accordance with four Classes of Services. It is therefore important
that a separate fee is indicated for each item of service performed.
- If total charges for a completed course of treatment are less than $300, check the box
noted "Statement of Actual Services" and complete items 23 through 39. The claim form should then be sent to the address shown
below.
- If total charges for a course
of treatment are expected to be $300 or more, check the
box noted "Pre-Treatment Estimate" and complete
items 23 through 39. The completed claim form should be
sent to MetLife prior to the commencement of the
course of treatment. Metropolitan will review the claim
(and any supplementary information required) and notify
your patient of the benefits payable.
- A pretreatment estimate of benefits is not intended to preclude a course of treatment agreed
upon by you and your patient. The intent is to avoid any misunderstanding concerning the benefits payable under the dental plan. A pretreatment
estimate is not necessary for oral examinations, cleanings, fluoride applications, dental x-rays, or emergency treatment.
- If the address where treatment was performed is different from the mailing address
in item 24, complete item 40.
- Generally, we do not
request x-rays where standard filling materials are used.
Pre-operative x-rays are requested only in connection
with prosthetics, fixed bridgework, or cast restorations.
Occasionally we may request x-rays that relate to other
dental services.
- In an effort to reduce your
costs and inconvenience, we request your cooperation in
submitting x-rays only in the above mentioned circumstances
or when specifically requested. This will also enable us
to expedite the processing of a pretreatment estimate.
- If authorized by the employee, benefit payment will be made directly to you.
Information for Mailing and 800 Line
Mail completed form with
original bill to:
MetLife Dental Claims
P.O. Box 981282
El Paso, TX
79998-1282
Call toll free for claim information eligibility or personalized PDP directories to:
800-984-8649.
If you, the member, are unhappy with your Explanation of Benefits and have asked Met for a review, and
have already received a second review from them that you believe contains error, you may file a final Dental Claim Appeal with the Trust.
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