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

Please Review Before Submitting Claim

Information for Employee

1. Complete your section of the claim form (items 1 through 22) in full to assure 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. The

patient

(or parent if patient is a minor) must sign item 20.

3. You must sign the claim form in item 22.

4. You can arrange for Metropolitan to make payment directly to the dentist by completing item 21. If you wish benefits to be

paid directly to yourself, do not complete item 21. In either case, a statement of benefits paid will be sent to you.

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 Metropolitan prior to the commencement of the course of treatment for a pretreatment estimate of benefits.

Metropolitan 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 booklet 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 Metropolitan 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.

4. If the address where treatment was performed is different than the mailing address in item 24, complete item 40.

5. Generally, we do

not

request x-rays where standard filling materials are used. Pre-operative x-rays are requested

only

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.

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

Mail completed form to:

MetLife Dental Claims

P. O. Box 14093

Lexington, KY 40512-4093

Claim Inquiries:

1-800-942-0854

Dental Insurance Claim Form Metlife Page 2

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