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}}

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{{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

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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}}

Effective Date

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

Plan Year Begins

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Eligible

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Essential Health Benefits

{{memberselected.ehbIndicator}}

Term Date

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

Product Description

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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

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.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