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