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