Out-of-network dentists may charge you more than the maximum allowed charge (which is the maximum amount that an in-network dentist has agreed with us to accept as payment in full for a covered dental service). This is commonly referred to as 'balance billing'. If an out-of-network dentist performs a covered service, you’ll be responsible for paying:
- any deductible required under your plan;
- any percentage of the maximum allowed charge for which we do not pay benefits for out-of-network services; and
- the difference in amount between the maximum allowed charge and the actual amount charged by the out-of-network dentist (the 'balance bill').
You may receive a separate bill from the out-of-network dentist for this excess amount.
Emergency dental services, if required, may be obtained from any provider, including an out-of-network dentist, at no additional cost.
If an in-network dentist is not available to you, there may be exceptions and limitations to the amount you will need to pay for covered services by an out-of-network dentist based on your location. Please contact us for assistance and additional information.
You can get a claim form from your employer and return the completed claim form, with any required proof, back to your employer. Your employer will certify your insurance under the group policy and send the certified claim form and proof to us.
You can also get all the claim forms needed to file for benefits under the group insurance program by calling us at 1-800-942-0854, or by visiting www.metlife.com/dental and selecting "Download Claim Form."
When you file a claim, both the claim form and any required proof should be sent to us within 90 days of the date you (or your dependent) received the covered service.
However, even if we don’t receive the claim form and required proof within 90 days, this won’t mean your claim is denied or reduced if we get the information as soon as is reasonably possible. This information should be mailed to:
MetLife Dental Claims
P.O. Box 981282
El Paso, TX 79998-1282
Or faxed to: 1-859-389-6505.
For DHMO, we do not require claim forms.
A retroactive denial is the reversal of a previously paid claim, where you become responsible for payment. You won’t be subject to retroactive denials as MetLife Dental doesn’t retroactively deny claims.
For group dental insurance, we receive the premium from the group employer and not from the individual member. Therefore, if you need a refund of a premium overpayment, please contact your employer.
No, we don’t need prior approval for any covered services but, our dental consultants may review submitted claims for medical (dental) necessity.
If you have questions about whether certain services recommended by your dentist are considered medically (dentally) necessary and covered by your plan, you can ask for a pre-treatment estimate of benefits for the dental services to be provided. The pre-treatment estimate is submitted by your dentist beforehand to help you better understand what your out-of-pocket costs for the service will be.
The Explanation of Benefits (EOB) is a document we send to you after we’ve reviewed your dental claim(s), which shows how we determined your benefits. The EOB begins with a claim summary, providing an overview of your claim including the dentist’s submitted charges and the amount we paid you or the dentist. There’s also an overview of your plan and the status of important plan features, such as how much has been paid to date and remaining balances for your deductible or plan maximum. Plus, the EOB includes information about your right to appeal our benefits decision. We have posted a sample EOB Guide for your review. Visit www.metlife.com/dental and select "Download the Plan Participant EOB Guide."
You can view your EOB at any time by visiting www.metlife.com/mybenefits.
When you incur charges for covered services, but you are also covered by another plan, the other plan may also provide benefits for those same charges.
Coordination of Benefits (COB) rules exist to determine which plan pays first. When you are covered for dental services by more than one plan and allowable expenses are incurred, we apply the COB rules to determine which plan is primary and which is secondary.
If the MetLife plan is secondary, we may reduce what we pay based on what the other plan(s) pay. We do this by applying certain COB rules that are explained in detail in your certificate of insurance. To obtain all of the benefits available to you, you should file a claim under each plan that you are covered by. We may need to get in touch with you to get additional information to apply the COB rules.