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Patient
Select Patient:
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{{memberinfo.memberProfile.personName.middleName | uppercase}}
{{memberinfo.memberProfile.personName.lastName | uppercase}}
{{memberinfo.memberRelation.codeDesc | uppercase}}
{{memberinfo.memberAddress.postalAddress.addressLine1}}
{{memberinfo.memberAddress.postalAddress.city}},{{memberinfo.memberAddress.postalAddress.state}} {{memberinfo.memberAddress.postalAddress.zip5}}
{{memberinfo.memberAddress.postalAddress.city}},{{memberinfo.memberAddress.postalAddress.state}} {{memberinfo.memberAddress.postalAddress.zip5}}
DOB: {{memberinfo.memberProfile.dateOfBirth | date: "MM/dd/yyyy"}}
Spoken Language:
Language Assistance: No
Date of Service:
Insurance Information
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{{memberNetwork}}
{{memberNetwork}}
{{memberselected.eligibility.eligibilityIndicator==='Y'?"Eligible": ""}}
Not Eligible
No Essential Health Benefits
Essential Health Benefits
Subscriber ID:
Product ID:
{{memberselected.eligibility.product.codeValue}}
Product Type: {{memberselected.eligibility.productPlanType.codeValue}}
Product Line: {{memberselected.eligibility.plan.codeDesc}}
Group ID: {{memberselected.groupId}}
Group Name: {{memberselected.groupName}}
Plan Year Begins: {{memberselected.eligibility.planYearBeginDate}}
Provider Location
Page Access Date:
{{Pgroup.replaceAll("%20"," ")}}
Address:
{{PprovAddress1}}
{{Pcity}}, {{Pstate}} {{Pzip}}
{{Pcity}}, {{Pstate}} {{Pzip}}
Assignment Status:
Assigned Dentist: {{dhmoMessage}}
Dental Account Summary
Annual Maximum Benefits - Dental
Current Amount Used to Date:
$0
Deductible
Current Amount Used to Date:
$0
Lifetime Maximum Benefits - Orthodontics
Current Amount Used to Date:
$0
Benefit Details
Benefit
Breakdown
Coverage
and Deductible
Recent
Claims
Recent
Treatment Plans
Search or Filter by
ADA Search
Category Filter
ADA Search
ADA
Code
Code
ADA Description
Procedure
Category
Category
Service Dates
Service Date
Procedure Code Frequency
Procedure Code Frequency
Age
Limit
Limit
Alternate Benefit
Related Codes
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{{historyData.procedure.codeDesc}}
{{historyData.procedureCategory}}
{{historyData.serviceDateString}} {{historyData.serviceDateMoreString}}
{{(historyData.networkFrequency != null && historyData.networkFrequency !=
undefined && historyData.networkFrequency.length>0) ?
historyData.networkFrequency :'NA'}}
{{historyData.ageLimit == null || historyData.ageLimit == "" ? "NA" :
historyData.ageLimit}}
{{historyData.alternateBenefit == null || historyData.alternateBenefit == "" ?
"NA" : historyData.alternateBenefit}}
{{historyData.relatedCode == null || historyData.relatedCode == "" ? "NA" : historyData.relatedCode}}
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Claims Address: UNITED HEALTH CARE DENTAL CLAIMS PO BOX 30567 SALT LAKE CITY, UT 84130-0567
Payor Id: 521337971
Disclaimers
Disclaimer 1: This is the most current information that we have; however, it is the patient’s responsibility to check with the dental provider to verify they are participating and accept the patient’s plan. This is neither an authorization nor a guarantee of eligibility, benefits or payment.
Disclaimer 2: Some ADA codes require dental review guidelines. Predeterminations are highly recommended for procedures over $500.
Disclaimer 3: The information contained is a summary of the patient’s history. Absence of information indicates no history exists for the patient for that category/procedure but does not indicate that there are no limits on the plan.
Disclaimer 4: This document including attachments, may include confidential and/or proprietary information as designated by state or federal law, and may be used only by the person or entity to which it is addressed. If the reader of this document is not the intended recipient or his or her authorized agent, the reader is hereby notified that any dissemination, distribution, or copying of this fax is prohibited. If you have received this document in error, please notify the sender by calling customer service at 1-800-445-9090 and delete this document and its attachments immediately.
Disclaimer 2: Some ADA codes require dental review guidelines. Predeterminations are highly recommended for procedures over $500.
Disclaimer 3: The information contained is a summary of the patient’s history. Absence of information indicates no history exists for the patient for that category/procedure but does not indicate that there are no limits on the plan.
Disclaimer 4: This document including attachments, may include confidential and/or proprietary information as designated by state or federal law, and may be used only by the person or entity to which it is addressed. If the reader of this document is not the intended recipient or his or her authorized agent, the reader is hereby notified that any dissemination, distribution, or copying of this fax is prohibited. If you have received this document in error, please notify the sender by calling customer service at 1-800-445-9090 and delete this document and its attachments immediately.