{{preloginError}}
-
{{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
-
- 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}}
-
- Provider Location
{{PprovAddress1}}
{{Pcity}}, {{Pstate}} {{Pzip}}
- Assignment Status
Assigned Dentist : {{dhmoMessage}}
Dental Account Summary
{{memberNetwork}}
Annual Maximum Benefits - Dental
Deductible
Lifetime Maximum Benefits - Orthodontics
Benefit Details
| 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/ |
| Date Last Edited | Treatment Plan Name | Member Name | View Plan | {{treatmentPlanList}}
|---|---|---|---|
| {{item.lastUpdateDate | date: "MM/dd/yyyy"}} | {{item.treatmentName}} | {{item.memberName}} | Details |
Claims Address
Payor Id:
UNITED HEALTH CARE DENTAL CLAIMS PO BOX 30567 SALT LAKE CITY, UT 84130-0567
521337971