Dental Benefit Terms

Front 1

Allowable charge

Back 1

this is the maximum dollar amount allowed by the carrier; the patients benefit
payment is based on this for each dental procedure. This will only apply to dentist’s that are considered
“in-network” by the carrier

Front 2

Assignment of Benefits

Back 2

authorizes an insurance carrier to send payment directly to the treating dentist
for covered procedures performed on the patient

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Audit

Back 3

an examination or exploration of dental records or accounts to check their accuracy. This is to
make sure you are billing charges to the carrier appropriately

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Beneficiary

Back 4

a person who receives benefits under a dental benefit contract

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Birthday Rule

Back 5

coordination of benefits regulation stipulating that the primary payer of benefits for
dependent children is determined by the patents’ date of birth. This rule check the month and day only,
whichever parent’s birth date falls first in the year is primary regardless of age

Front 6

By report

Back 6

a narrative description used to report a service.

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Capitation

Back 7

a capitation program is one in which a dentist or group contract with the HMO or IPA to
provide all or most of the dental services covered under the plan to patients in return for payment on a
per-capita basis. For example a dentist may have 200 plan participants assigned to his practice and
receive $5.00 a month per patient however he may only treat 10 patients for that month

Front 8

Claim

Back 8

a request for payment under a dental or medical benefit plan

Front 9

Claim Form

Back 9

the form used to file for benefit payment under a dental plan. This is usually an ADA form
however you may use a medical HCFA or CMS 1500 form

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Coinsurance

Back 10

this is the portion of monies due from the patient after their insurance has paid their portion
of the claim. This is a cost share between the insurance and the patient, this fee is deemed by the
insurance carrier depending on the patients plan.

Front 11

Contract

Back 11

a legally enforceable agreement between two or more individuals or entities. This is usually a
contract between the insurance carrier and the dentist to participate in the dental plan

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Contract Dentist

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a contractual practitioner whom agrees to provide services. Typically under special
terms and conditions, while utilizing financial reimbursement arrangements.

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Coordination of benefits

Back 13

The method of integrating benefits payable for the same patient under more
than one plan. This may be between two dental carriers or a dental and a medical carrier. The amount
paid for all sources should NEVER exceed 100% of the total charges

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Copayment

Back 14

a set fee by the insurance carrier that the patient must pay when being seen or treated by
the dentist. This fee is usually between $5.00 to $30.00 per visit.

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Coverage

Back 15

Benefits available to an individual covered under a dental benefit plan

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Covered Services

Back 16

services for which payment is provided under the terms of the dental benefit contact.
What the insurance carrier will pay for.

Front 17

Current Dental Terminology (CDT)

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these are a list of codes and their descriptive terms published by the
American Dental Association (ADA) for reporting dental services and procedures to dental plans and
Medicaid.

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Current Procedural Terminology (CPT)

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these are a list of codes and their descriptive terms developed
by the American Medical Association (AMA) for reporting medical services and procedures to medical
plans and Medicare.

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Customary Fee

Back 19

the fee level determined by the dental plan for specific dental procedures to establish a
maximum benefit payable under a given plan for a specific procedure and area. The fee is usually
determined by totaling the fees charged by all the dentists in a given area and then averaging the fee
to come up with what should be customary

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Deductible

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the amount owed by the patient before the insurance plan will assume any liability for
payment of benefits. This is usually an annual fee and could range in price from $25.00 to $150.00

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Dental Health Maintenance Organization (DHMO)

Back 21

see Health Maintenance Organization

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Dependents

Back 22

This usually includes the spouse and children of the dental subscriber who will be covered
under the dental plan

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Direct Billing

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a process in which the dentist bills a patient directly for his/her fees

Front 24

Direct reimbursement

Back 24

a self-funded program in which the individual is reimbursed based on a
percentage of dollars spent for dental care provided, and which allows beneficiaries to seek treatment
from the dentist of their choice

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Discount Dental Plan

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this is a dental plan that has a set discount for a patient usually 20% to 30% off
the UCR fees

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Downcoding

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a practice of third-party payers in which the benefit code has been changed to a less
complex and/or lower cost procedure than was reported

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Eligibility Date

Back 27

the date an individual and/or dependents become eligible for benefits under a dental
benefit contract. Often referred to as the effective date

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Exclusions

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dental services that are not covered under a dental plan

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Exclusive Provider Organization

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also known as an EPO, this is a dental benefit plan that provides
benefits only if care is rendered by institutional and professional providers with whom the plan contracts
this is called an “in-network” provider

Front 30

Expiration Date

Back 30

the date on which the dental benefit contract expires. Also known as the coverage
termination date

Front 31

Explanation of benefits

Back 31

a written statement to a beneficiary and/or dentist from the insurance carrier
after a claim has been filed to indicate the benefit/charges covered or not covered under the plan. Also
known as an EOB

Front 32

Family deductible

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a deductible that is satisfied by combined expenses of all covered family members.
For example you may have an individual deductible of $25 and a family deductible of $75 regardless
of the number of family members you do not have to pay your individual deductible if the family
deductible has been met.

Front 33

Fee-for-Service

Back 33

a method of paying dentists on a service-by-service rather than a salaried or capitated
basis

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Fee Schedule

Back 34

a list of the charges established or agreed to by a dentist for specific dental services

Front 35

Flexible Spending Account (FSA)

Back 35

employee reimbursed account primarily funded by the employee
designated salary reductions. This fund may be used for any medical or dental expenses incurred. The
card usually looks like a Visa or MasterCard and may be ran through a credit card ma

Front 36

Health Maintenance Organization (HMO)

Back 36

a legal entity that accepts responsibility and financial risk for
providing specified services to a defined population during a defined period of time at a fixed price.

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Indemnity Plan

Back 37

a dental plan where a third party payer provides payment usually in the full amount of
the dentist fees.

Front 38

Individual Practice Association (IPA)

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a legal entity organized and operated on behalf of individual
participating dentists for the primary purpose of collectively entering into contracts to provide dental
services to enrolled populations. These dentist may practice in their own offices or in large group settings.

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Insurer

Back 39

an organization that bears the financial risk for the cost of defined services for a group of
beneficiaries

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Insured

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person covered by a dental plan or program

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International Classification of Diseases (ICD-9-CM)

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diagnostic codes designed for the classification of
morbidity and mortality information. These codes define the diagnosis or problem of the patient

Front 42

Liability

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an obligation for a specified amount or action

Front 43

Maximum allowable benefit (MAB)

Back 43

the maximum dollar amount a dental program will pay toward the
cost of dental care over a specified period of time, usually a calendar year

Front 44

Non-duplication of benefits

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when a subscriber is eligible for benefits under more than one insurance
plan a non-duplication of benefits may occur. This means if the primary carrier pays any amount toward
a covered procedure the secondary insurance carrier may not be liable for any cost incurred

Front 45

Overcoding

Back 45

reporting a more complex and/or higher cost procedure that what was actually preformed.
See also upcoding

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Payer

Back 46

this refers to the insurance carrier responsible for financing or reimbursing the cost of dental
services

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Point of Service (POS)

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arrangement in which patients with a managed care or HMO dental plan have
the option of using an “out-of-network” provider. The benefit to the patient is usually reduced.

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Preauthorization

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statement by a third-party payer indicating that proposed treatment will be covered
under the terms of the benefit contract

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Precertification

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confirmation by a third-party payer of a patient’s eligibility for coverage and coverage
determinations under a dental benefit program

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Predetermination

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submission of a treatment plan to the third-party payer for determination of benefits
before treatment is begun

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Pre-existing condition

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oral health condition which existed before a patient was enrolled in a dental
plan

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Preferred Provider Organization (PPO)

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a formal agreement between an insurance carrier and a dentist
to treat a specific patient population at a discounted rate. When a patient uses a PPO provider they
receive a larger benefit than using a non PPO provider

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Prefiling of fees

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The submission of a dentist fees to a carrier or third party payer for the purpose of
establishing, in advance, the dentist’s usual and customary fees

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Pretreatment estimate

Back 54

an estimate of benefits and allowable charges for treatment of covered services
by an insurance carrier. This will usually include the allowable amount, the expected reimbursement from
the insurance carrier and the expected amount owed by the patient

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Reimbursement

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payment made by a third party to the patient or dentist on behalf of the patient for
expenses incurred for a service covered by the dental plan

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Subscriber

Back 56

the person, usually the employee, who represents the family unit in relation to the dental plan

Front 57

Third-Party payer (TPA)

Back 57

an organization other than the patient (first party) or health care provider
(second party) involved in the financing of personal health services.

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Unbundling of procedures

Back 58

the separating of a dental procedure into component parts with each part
having a charge so that the cumulative charge of the components is greater than the total charge to
patients who are not beneficiaries of a dental plan

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Upcode

Back 59

using a procedure code that reflects a higher intensity service than would normally be used for
the services delivered

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Usual, Customary and Reasonable (UCR)

Back 60

the fees charged for a specific procedure set by the dentist
and/or insurance company that are usual and customary in their area

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Waiting period

Back 61

when a covered person becomes eligible for benefits. Most dental plans have a 3 to 12
month waiting period for Basic and Major services