Fillable Form Jy0333 - Dental Expense Claim (Page 3 of 4) in pdf

INSTRUCTIONS

(continued)

2. CLAIM SUBMISSION INFORMATION

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 (ID

Number) must be completed for the claim to be processed.

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 operations, 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 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.

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 or faxed to

the address or fax number 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 “Pretreatment Estimate” and complete items 23 through 42. 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 from the mailing address in item 24, complete item 43.

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 payments will be made directly to you.

Detach and submit the completed Dental Expense Claim Form to:

MetLife Dental Claims

Dentists’ telephone: 1-877-638-3379

P.O. Box 981282

El Paso, TX 79998-1282

Fax: 1-859-389-6505

If you are submitting a claim, please complete and detach the first page only and mail it to the above address or fax it to the number indicated. If you are

requesting that the form be translated into Spanish or Chinese, please visit our website, , and download the applicable claim form from our

Dental Insurance Center. Or you may mail the entire four (4) pages of this form to the address shown on page 4.

JY0333 (10/12)