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