A request for payment under a dental benefit plan; a statement listing services rendered, the dates of services, and itemization of costs. The completed request serves as the basis for payment of benefits.
Services and supplies which are reimbursed in whole or in part under the conditions of the dental benefit plan, subject to all the terms and conditions of the agreement or insurance policy. Charges are subject to any contractual agreements, exclusions and limitations. Any charges not covered by the plan are considered non-covered charges.