Frequently Asked Questions

A good dental plan makes it easier for you to protect your smile and save.¹ With the Preferred Dentist Program, you get coverage for cleanings, exams, X-rays and more. Keeping up with your dental cleanings and other preventive care now can help you avoid costly dental problems and treatments in the future.

Yes. We recommend that you request a pre-treatment estimate for services totaling more than $300. Simply have your dentist submit a request online or by phone. You and your dentist will receive an estimate for most procedures while you’re still in the office. Actual payments may vary depending upon plan maximums, deductibles, frequency limits and other conditions at time of payment.

A number of dental procedures, including:³

• Exams and cleanings
• Fillings
• X-rays
• Root canals
• And much more

Think about this: The average family of four spends $1,824 a year on dental services.⁴ Having a good dental plan in place can help you save money every year.¹ You also get protection against costly emergency dental treatments that may run into the hundreds or even thousands.

You and your eligible family members. For example, your spouse and dependents.

Dentists may submit claims for you which means you have little or no paperwork. You can track your claims online and even receive e-mail alerts when a claim has been processed. If you need a claim form, visit www.metlife.com/mybenefits or call 1 800 942-0854.

You can enroll:

• during open enrollment
• during a new hire eligibility period
• and during a qualifying life event

Yes. If your current dentist doesn’t participate in the network, encourage them to apply. To nominate your provider, visit metlife.com/mchcp/.

No. You don’t need to present an ID card to confirm that you’re eligible. You should notify your dentist that you’re enrolled in a MetLife dental plan with the PDP Plus Network and your group number is 215367. Your dentist can easily verify information about your coverage.

If MetLife denies Your claim in whole or in part, the notification of the claims decision will state the reason why Your claim was denied and reference the specific Plan provision(s) on which the denial is based. If the claim is denied because MetLife did not receive sufficient information, the claims decision will describe the additional information needed and explain why such information is needed. Further, if an internal rule, protocol, guideline or other criterion was relied upon in making the denial, the claims decision will state the rule, protocol, guideline or other criteria or indicate that such rule, protocol, guideline or other criteria was relied upon and that You may request a copy free of charge.

Appealing the Initial Determination

If MetLife denies Your claim, You may take two appeals of the initial determination. Upon Your written request, MetLife will provide You free of charge with copies of documents, records and other information relevant to Your claim. You must submit Your appeal to MetLife at the address indicated on the claim form within 180 days of receiving MetLife’s decision. Appeals must be in writing and must include at least the following information:

• Name of Employee
• Name of the Plan
• Reference to the initial decision
• Whether the appeal is the first or second appeal of the initial determination
• An explanation why You are appealing the initial determination.

As part of each appeal, You may submit any written comments, documents, records, or other information relating to Your claim.

After MetLife receives Your written request appealing the initial determination or determination on the first appeal, MetLife will conduct a full and fair review of Your claim. Deference will not be given to initial denials, and MetLife’s review will look at the claim anew. The review on appeal will take into account all comments, documents, records, and other information that You submit relating to Your claim without regard to whether such information was submitted or considered in the initial determination. The person who will review Your appeal will not be the same person as the person who made the initial decision to deny Your claim. In addition, the person who is reviewing the appeal will not be a subordinate of the person who made the initial decision to deny Your claim. If the initial denial is based in whole or in part on a medical judgment, MetLife will consult with a health care professional with appropriate training and experience in the field of dentistry involved in the judgment. This health care professional will not have consulted on the initial determination, and will not be a subordinate of any person who was consulted on the initial determination. MetLife will notify You in writing of its final decision within 30 days after MetLife’s receipt of Your written request for review, except that under special circumstances MetLife may have up to an additional 30 days to provide written notification of the final decision. If such an extension is required, MetLife will notify You prior to the expiration of the initial 30 day period, state the reason(s) why such an extension is needed, and state when it will make its determination.

If MetLife denies the claim on appeal, MetLife will send You a final written decision that states the reason(s) why the claim You appealed is being denied and references any specific Plan provision(s) on which the denial is based. If an internal rule, protocol, guideline or other criterion was relied upon in denying the claim on appeal, the final written decision will state the rule, protocol, guideline or other criteria or indicate that such rule, protocol, guideline or other criteria was relied upon and that You may request a copy free of charge.

Upon written request, MetLife will provide You free of charge with copies of documents, records and other information relevant to Your claim.

Coordination of benefits provisions in dental benefits plans are a set of rules that are followed when a patient is covered by more than one dental benefits plan. These rules determine the order in which the plans will pay benefits. If the MetLife dental benefit plan is primary, MetLife will pay the full amount of benefits that would normally be available under the plan, subject to applicable law. If the MetLife dental benefit plan is secondary, most coordination of benefits provisions require MetLife to determine benefits after benefits have been determined under the primary plan. The amount of benefits payable by MetLife may be reduced due to the benefits paid under the primary plan, subject to applicable law.

Look for a list of participating dentists online a
metlife.com/mchcp/.

You’re always free to select any general dentist or specialist. However, you usually save more when you visit a network dentist because he/she has agreed to accept negotiated fees as payment in full for covered services.

Negotiated fees refer to the fees that network dentists have agreed to accept as payment in full for covered services, subject to any co-payments, deductibles, cost sharing and benefits maximums. Negotiated fees are subject to change. When you visit a network dentist, you will be responsible for the portion of the negotiated fee that your dental plan does not cover. When you visit a non-network dentist, you will be responsible for the portion of the maximum allowed charge that MetLife does not pay plus any amount of the dentist’s actual charge that exceeds the maximum allowed charge.

As a hypothetical example, a dentist’s usual fee in Jefferson City, MO for a crown might be $1,125. The network negotiated fee is $688. The percentage covered is 50%. Your total out-of-pocket cost would be $344. This example assumes you’ve already satisfied the annual deductible and your annual maximum benefit has not been met.

As a hypothetical example, a dentist’s usual fee in Jefferson City, MO for a crown might be $1,125. The non-network maximum allowed charge is $688. The percentage covered is 50%. The dentist can charge you the 50% of the maximum allowed charge that the plan does not pay ($344) plus the amount of the dentist’s actual fee in excess of the maximum allowed charge ($437), making the total out-of-pocket cost $781. This example assumes you’ve already satisfied the annual deductible and your annual maximum benefit has not been met.