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