Plan Year HRA Pathology Self- funded Sealants Dental Caries Network Effective date Incurred date Class IV Prophylaxis Co- insurance Deductible Medicaid Preferred Provider Sinusitis Plan Maximums Third-Party Administrators Authorization ERISA EOB Preventive and Diagnostic Treatment Co- payment Balance Billing Medically Necessary Out-of- Network Out-of- Pocket Major Treatment Fiduciary Birthday rule Exclusions Termination date HSA Durable Medical Equipment Calendar Year Experimental and Investigational Holter Monitor Benefits Medicare Bruxism TMJ Authorized Personal Representative Plan Year HRA Pathology Self- funded Sealants Dental Caries Network Effective date Incurred date Class IV Prophylaxis Co- insurance Deductible Medicaid Preferred Provider Sinusitis Plan Maximums Third-Party Administrators Authorization ERISA EOB Preventive and Diagnostic Treatment Co- payment Balance Billing Medically Necessary Out-of- Network Out-of- Pocket Major Treatment Fiduciary Birthday rule Exclusions Termination date HSA Durable Medical Equipment Calendar Year Experimental and Investigational Holter Monitor Benefits Medicare Bruxism TMJ Authorized Personal Representative
(Print)
Plan Year
HRA
Pathology
Self-funded
Sealants
Dental Caries
Network
Effective date
Incurred date
Class IV
Prophylaxis
Co-insurance
Deductible
Medicaid
Preferred Provider
Sinusitis
Plan Maximums
Third-Party Administrators
Authorization
ERISA
EOB
Preventive and Diagnostic Treatment
Co-payment
Balance Billing
Medically Necessary
Out-of-Network
Out-of-Pocket
Major Treatment
Fiduciary
Birthday
rule
Exclusions
Termination date
HSA
Durable Medical Equipment
Calendar Year
Experimental and Investigational
Holter Monitor
Benefits
Medicare
Bruxism
TMJ
Authorized Personal Representative
