Fillable Metlife Dental Claim Form (Page 2 of 2) in pdf

If you are covered under a self-insured plan or insured under a policy issued in any state other than those listed below, or if

you reside in any state other than those listed below, then the following warning may apply to you:

Any person who knowingly and with intent to defraud any insurance company or other person files an

application for insurance or a statement of claim containing any materially false information or conceals, for the

purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act,

which is a crime and subjects such person to criminal and civil penalties.

If you are insured under a policy issued in one of the following states, or if you reside in one of the following states, one of

the following state warnings may apply to you:

New York (only applies to Accident and Health Benefits (AD&D/Disability/Dental): I know it is a crime to fill out

this form with facts I know are false or to leave out facts I know are important. I know that if I do this, I may also have to

pay a civil penalty of up to $5,000 plus the value of the claim.

Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim

containing any false, incomplete or misleading information is guilty of a felony of the third degree.

Massachusetts: Any person who knowingly and with intent to defraud any insurance company or other person files an

application for insurance or a statement of claim containing any materially false information or conceals, for the purpose of

misleading, information concerning any fact material thereto commits a fraudulent insurance act, and may subject such

person to criminal and civil penalties.

New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject

to criminal and civil penalties.

Oklahoma: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the

proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Kansas and Oregon: Any person who knowingly and with intent to defraud any insurance company or other person files

an application for insurance or a statement of claim containing any materially false information or conceals, for the purpose

of misleading, information concerning any fact material thereto may be guilty of insurance fraud, and may be subject to

criminal and civil penalties.

Virginia: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, files a

claim containing a false or deceptive statement may have violated state law.

Employee Signature _____________________________________________

Date __________________________________

Please Review Before Submitting Claim

Information for Employee

Complete your section of the claim form (items 1 through 21) in full to assure positive identification and prompt payment. Please print or type.

Note: Item 8 (Employee Social Security Number / ID Number)

Patient Consent. 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 professional 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.

You must sign the claim form 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.

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 booklet 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 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 the address shown below prior to the commencement of the course of treatment. MetLife will review the claim (and any

supplementary information required) and notify your patient of the benefits payable.

If the address where treatment was performed is different than 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 pre-treatment estimate.

If authorized by the employee, benefit payments will be made directly to you.

Mail Completed form to:

MetLife Dental Claims

P.O. Box 981282

El Paso, TX 79998-1282

Employees: 1-800-942-0854

Dentists: 1-877-638-3379

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