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For members of the Preferred
Choice and Quality Dental Plans
Who Should Use This Form
Union-represented State employees who are enrolled in the Preferred Choice or Quality Dental Plans should
use this form to request a formal review from MetLife.
The claim appeal form is
the last step in MetLife's claims process. Before completing
this form, you must first:
- Obtain services
- File your claim with MetLife
- Receive and read your Explanation of Benefits (EOB), which denies all or part of your
claim, and disagree with the denial
- Request a review of your EOB from MetLife (whether over the phone or in writing) and
- Receive a response from Met — this may be a letter or a second EOB.
If you've gone through the
steps outlined above, and you're still dissatisfied with the
benefit payment, complete this form.
You must submit this form no later than 60 days from the claim
review (step 5).
Mail your form to:
MetLife Dental Claim Unit
Union Benefits Trust Claims Review
5950 Airport Road
Oriskany, NY 13424
What Will Happen in Your Claim Appeal
Your claim will be reviewed by a MetLife appeal committee. Senior representatives from MetLife
and two dental consultants will examine your claim and applicable portion of the Trust's contract. The committee will answer your appeal within
90 days of your request. Their decision will be final.
How To Complete the Claim Appeal Form
Properly completing this form and including all relevant information will help to ensure your
appeal is examined accurately and efficiently. Along with a dated and signed form, make sure your appeal includes (if applicable for your claim):
- Initial Explanation of Benefits (EOB) Statement indicating payment for services and reason
for denial of all or part of claim
- Response to your review request (from step 5) — may be a letter or an EOB
- Receipts for expenses or canceled checks
- Dental records and/or
- X-rays.
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