Out-of-network dentists may charge you more than the maximum allowed charge (which is the maximum amount that the 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 will 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 received from an out-of-network dentist based on your location. Please contact us for assistance and additional information.
You can obtain 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 obtain all 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 this information is not supplied within this timeframe, the delay will not cause your claim to be denied or reduced if the information is given to us as soon as is reasonably possible. This information should be mailed to:
MetLife Dental Claims
P.O. Box 981282
El Paso, TX 79998-1282
A retroactive denial is the reversal of a previously paid claim, where you become responsible for payment. You will not be subject to retroactive denials as MetLife Dental does not retroactively deny claims.
For group dental insurance, we receive the premium from the group employer and not from the individual member. Therefore, if you require a refund of a premium overpayment, please contact your employer.
No, dental services do not require prior authorization or a prior determination of medical (dental) necessity. We do not require prior approval for any covered services. However, 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 request a pre-treatment estimate of benefits for the dental services to be provided. The pre-treatment estimate is submitted by your dentist prior to the services being rendered. It can 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 have reviewed your dental claim(s), which shows how we determined your benefits. The EOB begins with a claim summary, which provides an overview of your claim including the dentist’s submitted charges and the amount we paid you or the dentist. The EOB also provides an overview of your plan and gives you the status of important plan features, such as how much has been paid to date and remaining balances for your deductible or plan maximum. Additionally, 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."
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. This determination is made 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 additional information to apply the COB rules, and therefore, we may need to contact you to gather this information.