Eligibility Summary

Select Member

{{item.memberProfile.personName.firstName}} {{item.memberProfile.personName.middleName}} {{item.memberProfile.personName.lastName}}

Patient: {{memberinfo.memberProfile.personName.firstName | uppercase}} {{memberinfo.memberProfile.personName.middleName | uppercase}} {{memberinfo.memberProfile.personName.lastName | uppercase}}

{{memberinfo.memberAddress.postalAddress.addressLine1}}
{{memberinfo.memberAddress.postalAddress.city}},{{memberinfo.memberAddress.postalAddress.state}} {{memberinfo.memberAddress.postalAddress.zip5}}

DOB

{{memberinfo.memberProfile.dateOfBirth | date: "MM/dd/yyyy"}}

Relationship

{{memberinfo.memberRelation.codeDesc | uppercase}}

Spoken Language

{{memberinfo.lapAndHcrInfo.spokenLanguagePreference}}

Language Assistance

Yes No

Member has enhanced benefits. Refer to the Benefit Breakdown tab for applicable codes in RED
Select Plan:

Provider Network Status

{{memberNetwork}}

Subscriber ID

Product ID

{{memberselected.eligibility.product.codeValue}}

Product Type

{{memberselected.eligibility.productPlanType.codeValue}}

Group ID

{{memberselected.groupId}}

Group Name

{{memberselected.groupName}}

Product Line

{{memberselected.eligibility.plan.codeDesc}}

{{((memberselected.eligibility.fundingType == 'F') || (memberselected.parentGroupIdentifier=='10007' && memberselected.lineOfBusinessId!='0404' && memberselected.lineOfBusinessId!='0138' && memberselected.lineOfBusinessId!='0393') || memberselected.parentGroupIdentifier=='10072' || memberselected.parentGroupIdentifier=='10094' || memberselected.parentGroupIdentifier=='10041' || memberselected.parentGroupIdentifier=='10036') && memberselected.groupState == 'CA'? 'State Regulated':''}}

Effective Date

{{memberselected.eligibility.memberEligibilityEffectiveDate | date: "MM/dd/yyyy"}}

Plan Year Begins

{{memberselected.eligibility.planYearBeginDate}}

Eligible

{{memberselected.eligibility.eligibilityIndicator}}

Essential Health Benefits

{{memberselected.ehbIndicator}}

Term Date

{{memberselected.eligibility.eligibilityTermDate | date: "MM/dd/yyyy"}}

Product Description

{{memberselected.eligibility.product.codeDesc}}

M&R Quick Reference Guide
Provider Location

{{PprovAddress1}}
{{Pcity}}, {{Pstate}} {{Pzip}}

Assignment Status

Assigned Dentist : {{dhmoMessage}}

Annual Maximum Benefits - Dental

Deductible

Lifetime Maximum Benefits - Orthodontics

Procedure Category	Procedure Category Description	Coverage({{memberNetworkShort}})	Deductible Applies	Waiting Period Met Date
{{onceData.procedureCategory.codeValue}}	{{onceData.procedureCategory.codeDesc \| uppercase}}	{{onceData.coveragePct}}%	{{onceData.deductibleApplies}}	{{onceData.waitingPeriodMetDate \| date: "MM/dd/yyyy"}}N/A

Latest 10 service dates were displayed in the below table for each procedure code. If you wish to see more info please use Utilization Search

ADA Code	ADA Description	Procedure Category	Service Dates										Service Date Procedure Code Frequency* (i-ii-iii)	Age Limit	Alternate Benefit	Related Codes
{{historyData.procedure.codeValue}}	{{historyData.procedure.codeDesc}}	{{historyData.procedureCategory}}	{{historyData.services[0].serviceDate == null \|\| historyData.services[0].serviceDate == ""? "-" : historyData.services[0].serviceDate \| date: "MM/dd/yyyy"}}	{{historyData.services[1].serviceDate == null \|\| historyData.services[1].serviceDate == "" ? "-" : historyData.services[1].serviceDate \| date: "MM/dd/yyyy"}}	{{historyData.services[2].serviceDate == null \|\| historyData.services[2].serviceDate == ""? "-" : historyData.services[2].serviceDate \| date: "MM/dd/yyyy"}}	{{historyData.services[3].serviceDate == null \|\| historyData.services[3].serviceDate == ""? "-" : historyData.services[3].serviceDate \| date: "MM/dd/yyyy"}}	{{historyData.services[4].serviceDate == null \|\| historyData.services[0].serviceDate == ""? "-" : historyData.services[4].serviceDate \| date: "MM/dd/yyyy"}}	{{historyData.services[5].serviceDate == null \|\| historyData.services[1].serviceDate == "" ? "-" : historyData.services[5].serviceDate \| date: "MM/dd/yyyy"}}	{{historyData.services[6].serviceDate == null \|\| historyData.services[2].serviceDate == ""? "-" : historyData.services[6].serviceDate \| date: "MM/dd/yyyy"}}	{{historyData.services[7].serviceDate == null \|\| historyData.services[3].serviceDate == ""? "-" : historyData.services[7].serviceDate \| date: "MM/dd/yyyy"}}	{{historyData.services[8].serviceDate == null \|\| historyData.services[0].serviceDate == ""? "-" : historyData.services[8].serviceDate \| date: "MM/dd/yyyy"}}	{{historyData.services[9].serviceDate == null \|\| historyData.services[1].serviceDate == "" ? "-" : historyData.services[9].serviceDate \| date: "MM/dd/yyyy"}}	{{historyData.inNetworkFrequency != null && historyData.inNetworkFrequency != undefined && historyData.inNetworkFrequency.length>0 ? historyData.inNetworkFrequency : historyData.outOfNetworkFrequency != null && historyData.outOfNetworkFrequency != undefined ? historyData.outOfNetworkFrequency : '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}}
* Frequency Definition: i = Number of Procedure (999 = unlimited); ii = ProcedureFrequency Type (C=Calendar Year, F=Floating, P=Plan Year); iii = Period and Timeframe(D=Day, M=Month, Y=Year) Example: 1 F 36M read as 1 Procedure per 36 Floating Months

Subscriber ID	Amount Claimed	Claim Status	View
{{item.member.memberId \| maskNumber}}	$ {{item.totalCharge}}	{{item.claimStatusCode.codeDesc}}	EOB/ Details

Date Last Edited	Treatment Plan Name	Member Name	View Plan
{{item.lastUpdateDate \| date: "MM/dd/yyyy"}}	{{item.treatmentName}}	{{item.memberName}}	Details

Link to copay schedule

Claims Address Payor Id:

UNITED HEALTH CARE DENTAL CLAIMS PO BOX 30567 SALT LAKE CITY, UT 84130-0567

521337971

Dental Account Summary

Benefit Details