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Understanding the UnitedHealthcare Dental Provider Agreement

As one of the largest healthcare companies in the world, UnitedHealth Group provides a wide range of insurance, care, and technology services to millions of people. One of its subsidiaries, UnitedHealthcare, offers dental plans to individuals, employers, and government programs in all 50 states. To deliver dental benefits to its members, UnitedHealthcare contracts with dental providers, who agree to follow certain terms and conditions in exchange for payment. If you are a dentist, oral surgeon, orthodontist, or other dental professional who wants to participate in the UnitedHealthcare network, you need to sign a provider agreement and comply with its provisions. Here are some key aspects of the UnitedHealthcare Dental Provider Agreement that you should know.

Scope of Services

The provider agreement outlines the types of dental services that UnitedHealthcare covers and pays for, as well as any limitations or exclusions that apply. Generally, UnitedHealthcare dental plans cover preventive care, such as cleanings, exams, X-rays, and sealants; basic restorative care, such as fillings and extractions; and major restorative care, such as crowns, bridges, and dentures. The agreement may also specify additional services that require preauthorization or referral, such as implants, orthodontics, and oral surgery. Make sure you understand what services your participation in UnitedHealthcare entails and what the reimbursement rates are for each service.

Provider Responsibilities

The provider agreement sets out the expectations and obligations of dental providers regarding the quality and accessibility of care. For instance, UnitedHealthcare may require you to maintain certain credentials, licenses, and certifications, as well as keep accurate and timely records of your services and charges. You may also need to comply with state and federal laws, regulations, and guidelines, such as HIPAA, OSHA, and ADA. Furthermore, UnitedHealthcare may conduct audits, investigations, and surveys to evaluate your compliance with the agreement and with professional standards. Noncompliance can result in sanctions, penalties, or termination of the agreement.

Claim Submission and Payment

The provider agreement specifies the procedures and deadlines for submitting claims and receiving payment for your services. You may need to use specific billing codes, modifiers, and forms to itemize and justify your charges and attach any supporting documentation, such as X-rays or narratives. You may also need to submit claims electronically, through a secure web portal, or by mail. UnitedHealthcare may require you to submit claims within a certain period of time after the service, and may deny or adjust claims that are incomplete, inaccurate, or not medically necessary. You will also need to agree to accept UnitedHealthcare`s payment as payment in full, without charging members any additional amounts, except for copayments, coinsurance, or deductibles that are specified in the agreement.

Dispute Resolution

The provider agreement may include a mechanism for resolving disputes between you and UnitedHealthcare, such as mediation, arbitration, or litigation. You may need to follow certain steps before initiating a formal dispute, such as submitting a written notice or meeting with a UnitedHealthcare representative. Depending on the nature and severity of the dispute, you may have different options for resolution, such as seeking injunctive relief, monetary damages, or other remedies. Make sure you understand your rights and obligations in case of a dispute and consider consulting an attorney if necessary.

By signing a UnitedHealthcare Dental Provider Agreement, you can join a network of dental providers that serve millions of members and benefit from a steady stream of patients and revenue. However, you also need to be aware of the terms and conditions of the agreement, and make sure you comply with them to avoid any conflicts or consequences. If you have any questions or concerns about the provider agreement, you can contact UnitedHealthcare`s provider services for assistance.