Alternate Benefit Provision
Under the Preferred Dentist Program (PDP) Option, generally benefits will be limited to the R&C charge for the least expensive method of treatment that is appropriate and that meets acceptable dental standards — as determined by MetLife, the claims administrator. Under the Plan's alternate benefit provision, if MetLife determines in its sole discretion that a service less costly than the covered service the dentist performed could have been performed to treat a dental condition, the Plan will pay benefits based upon the less costly service if such service:
- Would produce a professionally acceptable result under generally accepted dental standards; and
- Would qualify as a covered service.
For example:
- When an amalgam filling and a composite filling are both professionally acceptable methods for filling a molar, MetLife may base the benefit determination upon the amalgam filling, which is the less costly service;
- When a filling and an inlay are both professionally acceptable methods for treating tooth decay or breakdown, MetLife may base the benefit determination upon the filling, which is the less costly service;
- When a filling and a crown are both professionally acceptable methods for treating tooth decay or breakdown, MetLife may base the benefit determination upon the filling, which is the less costly service; and
- When a partial denture and fixed bridgework are both professionally acceptable methods for replacing multiple missing teeth in an arch, MetLife may base the benefit determination upon the partial denture, which is the less costly service.
If the Plan pays benefits based upon a less costly service in accordance with these provisions, the dentist may charge you or your dependent for the difference between the service that was performed and the less costly service. This is the case even if the service was performed by an in-network dentist.
Certain comprehensive dental services have multiple steps associated with them. These steps can be completed at one time or during multiple sessions. For benefit purposes, these separate steps of one service are considered to be part of the more comprehensive service. Even if the dentist submits separate bills, the total benefit payable for all related charges will be limited to the maximum benefit payable for the more comprehensive service. For example, root canal therapy includes X-rays, opening of the pulp chamber, additional X-rays, and filling of the chamber. Although these services may be performed in multiple sessions, they all constitute root canal therapy. Therefore, the Plan will only pay benefits for the root canal therapy.
If a planned dental service is expected to cost more than $300, you have the option of requesting a pretreatment estimate of benefits. The dentist should submit a claim detailing the services to be performed and the amount to be charged. MetLife will provide you with an estimate of the dental insurance benefits available for the service.