Customer Service Updates Forms Search
Benefit Plans
Publications
Unions
FAQ
Contact Us
Links
Home
Forms

Dental Expense Claim Form

Please Review Before Submitting a Claim (Instructions apply to claim form, not appeal form)

Information for Member (Employee on this form)

  1. 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.
  2. 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.
  3. You must sign the claim form in item 21.
  4. 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.
  5. 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.)
  6. 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

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. If the address where treatment was performed is different from the mailing address in item 24, complete item 40.
  6. 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.
  7. 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.
  8. 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.