How to File a Claim

• Under Option 1, for an Out-of-Network Service Under Option 2, and Under Option 3
  A claim form should be completed as soon as you or your dependents incur a dental expense.

  For claims under $150 (or emergency treatment), submit a MetLife Dental Expense Claim Form (PDF). The standard American Dental Association claim form is also acceptable. Most dental offices have this form. You and your dentist must complete the claim form and return it to:

  MetLife Dental Claims
  P.O. Box 981282
  El Paso, TX 79998-1282

  If charges are expected to be more than $150, and are not for emergency services, your dentist should submit a Predetermination Plan. Your dentist can do this by filling out the appropriate section of the same claim form. Then you or your dentist send in the form to the address noted in the instructions. MetLife reviews the Predetermination Plan and advises the dentist of the amount eligible for reimbursement under the plan.

  Submit the claim form within 90 days of the date the expense was incurred, or be prepared to show that you submitted the claim as soon as reasonably possible. However, claims submitted more than two years after the expense was incurred will not be accepted. In submitting your claim, you will be required to provide written proof acceptable to the Plan regarding the date services were provided and the nature and extent of those services.

• Under Option 2 for an In-Network Service
  In Option 2, if you go to an In-Network provider, your dentist will handle your claim with MetLife. You will not have to submit any claim forms.

Assignment of Benefits
The benefits provided under the Plan are assignable to your dentist only.

Payment of Benefits
Subject to the Coordination of Benefits, all benefits are payable immediately to the assignee, if any. Otherwise benefits are payable immediately to you or to an alternate recipient, as described in the following section. If benefits are payable after your death, the plan has the option to pay benefits to your estate or to any of the following of your surviving relatives: spouse or other qualified adult, child(ren), parent(s), brother(s), and/or sister(s).

Coordination of Benefits (COB)
The University of Michigan Dental Plan has provisions for coordination of benefits with other dental plans covering you and your dependents. This prevents overpayments to dental care service providers. Coordination of benefits applies to you if you or any covered dependent has coverage under another dental plan. It is a way to make sure the payments to dental care providers from all plans do not exceed the total charge for covered services.

How COB Works
If you are covered by more than one group plan, COB guidelines determine which plan pays for covered services first.

• The plan that pays first is your primary plan. This plan must provide you with the maximum benefits available to you under the plan.
• The plan that pays second is your secondary plan. This plan provides payments toward the balance of the cost of covered services, up to the total allowable amount determined by the carriers.

Guidelines to Determine Primary and Secondary Plans
The University of Michigan Dental Plan, a group dental plan, determines benefits using the first of the following rules that applies:

1. If a group dental plan does not have a Coordination of Benefits provision, that plan is primary.
2. The plan that covers the patient as the employee is primary and pays before a plan that covers the patient as a dependent.
3. Dependent child of parents not separated or divorced when the UM plan and another plan cover the same child as a dependent:
1. the plan that covers the parent whose birthday falls earlier in the year determines benefits before the plan that covers the parent whose birthday falls later in the year; but
2. if both parents have the same birthday, the plan that has covered the parent longer determines benefits before the plan that has covered the other parent for a shorter period of time.
3. if the other plan does not have this rule for children of married parents, and instead the other plan has a rule based on the gender of the parent, and if as a result the plans do not agree on the order of benefits, the rule in the other plan determines the order of benefits.
4. Dependent child of parents divorced or separated through dissolution of a domestic partner relationship where two (2) or more plans cover the dependent child, this plan determines benefits in this order:
1. first, the plan of the parent with custody of the child;
2. then, the plan that covers the spouse of the parent with custody of the child;
3. finally, the plan that covers the parent not having custody of the child;
4. in the case of joint custody, b. above applies; or
5. if the court decree requires one (1) of the parents to be responsible for the dental care expenses of the child, and the plan that covers that parent has actual knowledge of that requirement, that plan determines benefits first. This does not apply to any claim determination period or plan year during which any benefits are actually paid or provided before the plan has that actual knowledge.
5. Active/inactive employee — The Plan that covers a person as an employee who is neither laid-off nor retired (or as that employee's dependent) determines benefits before a plan that covers that person as a laid-off or retired employee (or as that employee's dependent). If the other plan does not have this rule, and if as a result the plans do not agree on the order of benefits, then this rule is ignored.
6. Longer/shorter length of coverage — If none of the above determines the order of benefits, the plan that has covered an employee, member, or subscriber longer determines benefits before the plan that has covered that person for a shorter time.

Right of Recovery
If this plan pays more than it should have paid under these coordination of benefit rules, this plan may recover the excess from any of the following:

1. the persons this plan paid or for whom this plan has paid;
2. insurance companies; or
3. other organizations.

The amount paid includes the reasonable cash value of any benefits provided in the form of services.

Medicaid
Payment of benefits will also be made in accordance with any assignment of rights made by or on behalf of a participant or beneficiary as required by a state's Medicaid program. Determination and payment of benefits under the Plan will not take into account that a Plan participant is eligible for or covered by Medicaid.

Payment of benefits will be made in accordance with any state law which provides that the state has acquired the rights of the participant or beneficiary with respect to items or services the plan has a legal obligation to pay, but only to the extent the state has made payment for the benefits under the Medicaid program.

Qualified Medical Child Support Orders
Benefits will be paid to an alternate recipient, or the alternate recipient's custodial parent or legal guardian, if a Qualified Medical Child Support Order has been received by the Benefits Office. See Medical Child Support Order and Qualified Medical Child Support Order for more information.

Refund to the Plan for Overpayment of Benefits
The Plan will have the right to a refund from you if the Plan pays dental benefits to you for dental expenses incurred by you or a dependent, and it is found that the Plan paid more dental benefits than the Plan should have paid for reasons including but not limited to:

• all or some of those expenses were not charges the faculty or staff member or an enrolled dependent were legally obligated to pay; or
• any enrolled faculty or staff member who was repaid for all or some of those expenses by a source other than the Plan including any lawsuit or settlement from a third party.
• you and your spouse or other qualified adult are both employed by the University and one received double coverage as both employee and dependent. Similarly, the Plan has the right to a refund from you if your child receives coverage under two different benefit options, or you, as an employee, use your benefit plan to cover a University retiree who has his or her own University coverage.

Calculation of Refund
The amount of the refund is the difference between:

• the amount of dental benefits paid by the Plan for those expenses; and
• the amount of dental benefits which should have been paid by the Plan for those expenses.