UNITEDHEALTHCARE DENTAL

The UnitedHealthcare Dental plan offers both an "indemnity plan" and a "participating dentists" plan.

When you visit your dentist, the dentist's office will verify benefits with UnitedHealthcare Dental Claims Department (phone # on back of ID Card), perform the work and submit the billing on an acceptable ADA claim form. If benefits are assigned to the dentist, benefits will be paid directly to his office. In most instances, it is not necessary for the insured to complete a claim form.

Benefits are based on the Usual and Customary fees charged in the area where service is rendered.

UnitedHealthcare Dental is available in all states. Rates are based on your Area Classification (the first 3 digits of your zip code) and the number of persons to be covered:

UnitedHealthcare Dental Plan Links and Forms

INDEMNITY PLAN -- Available in all States:

(All forms are in PDF format. If you cannot
print a form, please call 1-800-221-3083
and we will be glad to mail forms to you.)

Form / Link	Purpose
Enrollment Form	To participate in the Indemnity Plan, an Enrollment Form must be completed, signed and mailed to Mass Benefits Consultants, Inc.
Area Classification Chart	The Premium Rate Area is determined by the first 3 digits of your home zip code.
Bi-Weekly Rate Chart	After you determine your Premium Rate Area, the Bi-Weekly rate chart gives you the cost for the number of family members you want to enroll if you pay by Payroll Deduction.
Monthly Rate Chart	After you determine your Premium Rate Area, the Monthly rate chart gives you the cost for the number of family members you want to enroll if you pay Monthly by automatic bank draft. Quarterly billing option is also available.
Direct Deposit Form	Complete this form if you want to pay by payroll deduction and your Payroll office processes the form.
Employee Express Form	Use this information if you want to pay by payroll deduction and you must start the deduction yourself through HR Links or Employee Express online.
Monthly Bank Draft	Complete and return this form with a voided check to pay your premium on a monthly basis.
www.myuhcdental.com	This link will give you a list of dentists that are affiliated with UnitedHealthcare Dental (Passive PPO Network). You are not required to use these dentists, but your co-payment amounts may be less if you do because of the Usual and Customary limitations.
Claim Form	Call the Claim Office toll free - 1-877-816-3596 for a claim form.

 

If you are a resident of California or Texas - view the DHMO option

Coverage will begin after the application and premium payment have been
received. See the Enrollment Chart for application deadlines and coverage effective dates.

Mass Benefits Consultants, Inc. handles all enrollment and billing. If you have any questions, please e-mail us (and leave a daytime phone number).

UnitedHealthcare Dental Benefits Summary

$50 Annual Deductible is Per Insured Person (Maximum $150 per family)
Benefit Structure	Waiting Period
Type I - Preventive Services Clinical Oral Exams, Fluoride treatments (under age 19), X-rays, Cleanings UnitedHealthcare Dental Pays 100% Services subject to annual deductible	None
Type II - Basic Services Extractions, Fillings UnitedHealthcare Dental Pays 80% for In-Network Dentists UnitedHealthcare Dental Pays 50% for Out-of-Network Dentists Services subject to annual deductible	6 Months
Type III - Major Care Endodontics, Periodontics, Oral Surgery, Surgical Extractions, Inlays and Onlays, Crowns, Dentures and Bridges UnitedHealthcare Dental Pays 50% Services subject to annual deductible	12 Months
One Annual Deductible Per Insured Person. Maximum of three deductibles per family.	$50 Per Person $150 Per Family Maximum
Combined Calendar Year Maximum	$1,000

All benefits are subject to the provisions of the group policy form issued to the association. Each participant will receive a Certificate of Insurance and ID Card.

NOTES

• Benefit Year is one year from the effective/renewal date of the group's Master Policy.
• The Deductible applies to each insured person each Calendar year.
• This plan has a Coordination of Benefits provision.
• Percentages shown as "UnitedHealthcare Dental Pays" above pertain to the Usual and Customary charges of a provider in the area where the service is rendered.
• Pre-existing Condition Limitation - UnitedHealthcare Dental will not cover replacement of a tooth extracted prior to the Certificate Effective Date.
• Children's coverage - both natural and adopted children up to age 19, or to age 23 if enrolled full-time at an accredited institution (and not working full-time).
• In-Network Dentists information (including name, telephone number and location) is found at www.myuhcdental.com

ENROLLMENT CHART

If your application is received by this date, and payment is received prior to the coverage effective date:	Coverage will begin on this date:
January 15	March 1
February 15	April 1
March 15	May 1
April 15	June 1
May 15	July 1
June 15	August 1
July 15	September 1
August 15	October 1
September 15	November 1
October 15	December 1
November 15	January 1
December 15	February 1

UNITEDHEALTHCARE DENTAL ENROLLMENT INSTRUCTIONS

• Complete all requested information on the Enrollment Form.
• Find the first 3 digits of your home zip code in the Area Classifications to determine the rate Area. The Rate Charts are available by payment modes (Bi-Weekly, Monthly, and Quarterly).
• Choose payment method and print appropriate forms from our website www.massbenefits.com:

  Payroll Deduction - choose:Direct Deposit Form or  Employee Express/HR Links Format
  (Check with your payroll office to determine the appropriate method:)

  Direct Deposit Form is mailed to your payroll office.

  Employee Express/HR Links Format provides information for your online connection to your payroll office.

Monthly Check Service - include the Monthly Check Service Form and a check for the first month's premium.

Quarterly Direct Bill - upon receipt of your Enrollment Form, we will mail you a "Notice of Payment Due" invoice.

• Mail to:

Mass Benefits
P.O. Box 828
Annandale, VA 22003-0838