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