PRE-DETERMINATION OF BENEFITS. Usually, before starting extensive dental work, your dentist will tell you what he intends to do and the charge. If the cost of a course of treatment planned by the dentist for a covered family member is expected to exceed $200.00, the proposed course of treatment must be filed with, and approved by, the Insurance Company prior to the commencement of treatment. The necessary forms are available from your Employer. After reviewing the proposed course of treatment, the Insurance Company will notify both you and your dentist of the estimated payment under the Plan. Because of the difficulty of determining the necessity for the types of services involved after treatment has been received, failure to file and obtain approval may result in benefits of a lesser amount than would otherwise have been payable. Occasionally a patient may select a more expensive procedure rather than a suitable alternate procedure. In such cases, reimbursement will be based on the least expensive procedure, which as determined by the Insurance Company, will produce a professionally adequate result.
PRE-DETERMINATION OF BENEFITS. If a course of treatment can reasonably be expected to involve Covered Dental Expenses of $200 or more, a description of the procedures to be performed and an estimate of the dentist's charges must be filed with the Carrier prior to the commencement of the course of treatment. The Carrier will notify the employee and the dentist of the benefits certified as payable based upon such course of treatment. In determining the amount of benefits payable, consideration will be given to alternate procedures, services, or courses of treatment that may be performed for the dental condition concerned in order to accomplish the desired result. The amount included as certified dental expenses will be the appropriate amount as provided in subsections (d) and (e) herein, determined in accordance with the limitations set forth in subsection (g) herein. If a description of the procedures to be performed and an estimate of the dentist's charges are not submitted in advance, the Carrier reserves the right to make a determination of benefits payable taking into account alternate procedures, services, or courses of treatment, based on accepted standards of dental practice. To the extent verification of Covered Dental Expenses cannot reasonably be made by the Carrier, the benefits for the course of treatment may be for a lesser amount than would otherwise have been payable. This pre-determination requirement will not apply to courses of treatment under $200 or to emergency treatment, routine oral examinations, x-rays, prophylaxis, and fluoride treatments.
PRE-DETERMINATION OF BENEFITS. If a dental bill is expected to be $125 or more, before the Dentist starts the treatment, a Covered Person can find out what Dental Expense Benefits will be paid under This Plan. To do this, the Covered Person should send a claim form to MetLife in which the Dentist tells MetLife:
