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