Complete List Of Dental Plans Benefit Terms
In Plain And Simple English

Glossary of Dental Insurance Benefits


A - C

Administrative Costs - overhead expenses incurred in the operation of a dental benefit program, exclusive of costs of dental services provided.

Administrative Service Only (ASO) - administrates self-funded dental benefit plans, insurance companies - Third Party Administrators (TPA) that process and pays claims.

Alternative Benefit - when two different types of dental treatment are considered adequate, dental benefit plans will opt to pay for lesser treatment, even if more expensive treatment is considered better treatment. Also known as Least Expensive Alternative Treatment (LEAT).

Assignment Of Benefit - an arrangement in which dental benefit plans spell out exactly what payments they will make to dentist on behalf of patients. Payments are paid directly to the dentist. You, the patient are responsible for deductibles and co-payments.

Benefits - the services covered, or the dollar amount/percentage of dental fees paid by dental benefit plans.

Benefits Package - in regards to dental/health care benefits, these benefits include dental, medical, vision, chiropractic and prescription care.

Benefit Plan Summary - the description or synopsis of employee benefits as required by ERISA, to be distributed to the employees.

Benefit Period - amount of time a benefit package is in effect, usually for one year. With some dental benefit plans each new benefit year carries a new deductible, and a new maximum yearly dollar amount limits, and maximum allowable visits per year.

Birthday Rule - when two members of the same family are insured, usually by different employers. The family member whose birthday comes first in calendar year - not the oldest - is primary insured party.

Cafeteria Plan- benefit package in which employees are given a certain amount of fringe benefit dollars. These benefit dollars can then be applied to specific or desired benefits - medical, dental, child care, day care, etc.

Capitation Fee - a fixed monthly allowance paid to participating dentists by a DHMO, for each patient assigned to the dentist. The dentist uses this "pre-paid" fee to cover the costs of providing patient care (see capitation plan below).

Capitation Plan - dental benefit plans in which, dentists agrees to service all dental care needs of patients enrolled in plan for a fixed monthly payment by plan. Payments are made on a per capita basis, whether or not you, the patient presents for treatment. Also referred to as DHMO's or Dental Health Maintenance Organizations (see capitation fee above).

Cash Card - you are paying the balanced owed, when you pay for services with a cash card.

Claim Form - or claim, written proof dental treatment has been performed. Claim forms are submitted to dental benefit plans for payment of services. Some dental benefit plans process forms electronically.

Closed Panel (Network) - a specified network of dentists. If you, as a patient go to a dentist that is NOT included in panel, then the dental benefit plan will usually either provide you NO benefits, or reduced benefits.

Co-Insurance - percentage of dental care expenses you pay after your deductible. Your dental insurance plan pays the rest up to any lifetime maximum.

Co-Insurance/Double Coverage - occurs when two parties in a family have different dental benefit plans from their respective employers. Usually, the family member whose birthday month comes first in the calender year is the primary insured party - also known as the birthday rule.

Co-Payment - when dental benefit plans do not pay for the entire cost of treatment. Remaining portion of cost is yours, the patient's responsibility.

Contract Dentist - a provider who agrees to offer specified services at specific levels of reimbursement, under the terms and conditions agreed to by contract - with the enrolling plan.

Contract Term - the period of time - usually 12 months - that a contract is written.

Coverage (Covered Treatment) - the amount and type of services paid for by the insurance company.

Credentialing - process by which dental benefit plans selects dentists who are allowed to render services to patients enrolled in plan. Dental benefit plans use credentialing process as a means of quality of control in selecting "approved" dentists.

Current Dental Terminology (CDT) - the ADA reference manual containsing the Code on Dental Procedures and Nomenclature and other information pertinent to patient record keeping and claim preparation by a dental office; published biennially.

Customary Fee - the fee determined by dental benefit plans for a specific service, usually done by a panel of dentists.

D - F

Deductible - the amount of dental expense for which you as the enrollee is responsible to pay, before a third party (dental-benefit-carrier) will authorize it's share of payments.

Dental Benefit Plans - refers to the many different types or structures of dental plans, including the 5 major types of dental plans; DHMO's, PPO's, Indemnities, Direct Reimbursements and Dental Discount Plans.

Dental Carrier - insurance company or dental benefit plan that actually write the dental policy terms or contract. Unlike Third Party, the Carrier is the party responsible for coverage and payments.

Dental Discount Plan(DDP) - DDPs' guarantee you dramatic discounts on dental procedures, including specialist services. DDP's also offer deep discounts on monthly premiums or fees. You receive your authorized discount and pay for services at time of treatment - you're free to set-up monthly payment terms with your dentist. Ameriplan is an example of a DDP.

Dental Exclusive Provider Organization (DEPO) - similar to a Dental PPO - Dental EPO's are dental benefit plans in which the insurance company negotiates fees with a network of dentists in return for guaranteeing a specified volume of patients to dentists. You, as a patient receive no benefits if you seek treatment from a dentist outside of network.

Dental Insurance - indemity plans (traditional plans). A payment system in which these type dental benefit plans are financially responsible for part, or all of treatment cost. These plans are noted for their "freedom of choice" in selecting dentists on one hand - while ironically being noted for their limitations on yearly visits - on the other hand.

Dental Service Corporation - non-profit company, usually organized by health professionals to administer dental benefit plans. Blue Cross and Delta Dental Plans are examples of dental service organizations.

Direct Reimbursement - a method of providing benefits through which an employer reimburses employees directly for their dental care expenses, instead of purchasing insurance coverage from a third party.

DHMO or Dental HMO: Dental Health Maintenance Organization - pre-paid dental benefit plans in which you, the patient receives care through a network of dentists, who are either salaried employees of the DHMO, or who are under contract to DHMO. Dentists receive compensation based on a capitation fee arrangement (see cap fee).

Down-coding - a third-party payers practice in which the benefit code has been changed to a less complex and/or lower cost procedure than was reported, except where noted in contract agreements.

Eligibility Date - the date you as the individual and/or your dependents, become eligible for benefits under a dental benefit plan contract - usually, referred to as the "effective date".

Employment Retirement Income Security Act (ERISA)- a federal act, passed in 1974, which established new standards and reporting/disclosure requirements for employer-funded pension and welfare benefit programs. To date, self-funded health benefit plans operating under ERISA have been held to be exempt from most state insurance laws.

Exclusions - dental services NOT covered by dental benefit plans contract or program.

Exclusive Provider Organization (EPO) - similar to a Dental PPO - Dental EPO's are dental benefit plans in which the insurance company negotiates fees with a network of dentists in return for guaranteeing a specified volume of patients to dentists. You, as a patient receive no benefits if you seek treatment from a dentist outside of network.

Fee For Service - an arrangement under which the dentist is paid for each service rendered according to a fee schedule agreed upon by dentist and the payor organization (ex. discount dental plans).

Fee Schedule - a list of charges for specific dental procedures established by, or agreed to by dentists.

Flexible Spending Account (FSA) - an employee reimbursement account funded primarily by employee - designated salary reductions. Funds are reimbursed to employee for health care (medical, dental, dependents care, and/or legal expenses, and are considered a non-taxable benefit.

Freedom Of Choice - concept that you as the patient has the right to choose any licensed dentist you want, to deliver your oral health care without any type of coercion on behalf of dental carrier.

Full Cafeteria Plan - usually includes POP and FSA features (see terms). Under this type plan employees receive a lump sum of money to spend on their benefits, while employer provides a menu of benefit options for employees to choose from.

Funded Card - provided to enrollees of dental benefit plans. You as the patient use these credit card like instruments to make payment, if you owe money after payment is made by third party.

G - P

Gatekeeper - concept unique to capitation dental benefit plans (HMO/DHMO), refers to the primary care provider. You, the patient must first visit Gatekeeper for treatment. If specialist care is needed and approved, you must then go to a specialist refer by gatekeeper.

Health Insurance Portability and Accountability Act (HIPAA) - a federal law requiring all health plans, including ERISA, as well as health care clearinghouses and any dentist who transmits health information in an electronic transaction, to use a standard format. HIPAA also requires use of the ADA’s Code on dental procedures and nomenclature . Paper transactions are not subject to requirement.

Health Savings Account (HSA) - is a special account owned by you, the individual (patient), contributions made to your account can be used to pay for both current and future medical expenses. HSA's must be used in conjunction with a "High Deductible Health Plan" (HDHP).

High Deductible Health Plan (HDHP) - these plans must be used together with HSA, you must have a HDHP before you can set up a HSA. HDHP have a minimum deductible of $1000. for self-only coverage - $2,000 for family coverage.

HMO/Health Maintenance Organization - also called capitation dental benefit plans. You, the patient are assigned a primary care dentist, usually a general dentist. If specialty care is needed, general dentist/gatekeeper refers you to a plan specialist. Dentist receives a set monthly fee per patient, and provides all necessary services at no additional charge to you, or the employer.

Indemnity Insurance - dental benefit plans - usually an insurance company - pays for all or part of dental treatment. You, the patient has complete "freedom of choice" in selecting a dentist, and you can go directly to a specialist without referral by a general dentist.

Individual Practice Association (IPA) - : a legal entity organized and governed by individual participating dentists for the primary purpose of collectively entering into contracts to provide dental services to enrolled populations.

Least Expensive Alternative Treatment (Leat) - a limitation found in most dental benefit plans (insurance specific plans), which reduces payable benefits to the least expensive of all posible treatment options. Patients choosing the most appropriate (most expensive) treatment plan will incur significant out-of-pocket expenses.

Limitations - restrictive conditions stated in a dental benefit contract, such as age, length of time covered, and waiting periods, which affect an individual’s or group’s coverage. The contract may also exclude certain benefits or services, or it may limit the extent or conditions under which certain services are provided.

List Bill - an itemized list of employees, social security numbers and benefit plan options, submitted to a dental discount plan when a group account is written.

National Association of Insurance Commissioners (NAIC) - professional or trade association for state departments of insurance

National Provider Identifier (NPI) - this is an identifier assigned by the federal government to all providers considered to be HIPAA covered entities. Dentists who are not covered entities may elect to obtain an NPI at their discretion, or may be enumerated if required by a participating provider agreement with a third-party payer.

Manage Care - health care delivery system created to control costs while guaranteeing a minimal level of care. Term usually refers to HMO's, although it is often use to refer to PPO's and Dental Service Corporations, too. Manage care is any system where dentists agree to limitations on "usual and customary fees" for service.

Network - list of dentists who have agreed to a particular dental benefit plan's rules, regulation and fee schedule. Discount dental benefit plans are noted for their hugh networks of dentists.

Open Panel - a provision withing certain dental benefit plans which allow you, the patient to go to any dentist of your choice. Dental discount plans are a great example of open panel plans.

OSHA - Abbreviation for Occupational Safety and Health Administration. Federal agency in the US responsible for making and enforcing employee safety regulations.

Out-Of-Pocket Expenses - includes deductible, co-payments, orthodontia (braces), dental treatments, x-rays and laboratory services.

Over-coding - reporting a more complex and/or higher cost procedure than was actually performed.

Peer Review - committee of dentists selected by dental benefit plans/companies, states, or local dental association for the purpose of hearing patient complaints against a dentist.

Point Of Service Plan (POS) - managed care dental benefit plans allowing you, the patients to seek treatment from a non-participating dentist (out-of-network), but at much lower benefits levels (higher co-pays for patients).

Pre-authorization/Pre-determination - administrative procedures requiring dentists to submit a treatment plan to a third party payer (insurance carrier), for approval before treatment is begun.

Pre-certification - confirmation by a third-party payer of a patient’s eligibility for coverage under a dental benefit program.

Preferred Provider Organization (PPO) - dental benefit plans (insurances) that negotiates fees with dentist and directs patients to those dentist offices. When you receive treatment outside of this type network, you pay a higher co-payment and/or deductible.

Premium - regular monthly fee (typically monthly), charged to you, the enrolled, by third-party insurers. Monies used to fund dental benefit plans.

Premium Only Plan (POP) - an as aspect of Section 125 Health Plans - employees premium contributions are automatically deducted from salaries before taxes are taken out.

Provider Access Organization - dental benefit plans providing their members access to a select network of dental/healthcare providers. These plans are noted for providing members access to persons who normally wouldn't have access to an employer sponsored health/dental benefit plan.

R - Z

Reasonable Fee - fee determined by dental benefit plans when there are special circumstances causing a higher degree of difficulty for dentist, and subsequently higher cost. Reasonable Fee is greater than Usual Fee.

Reimbursement - payment made by a third party to you the beneficiary, or to a dentist on your behalf - repayment of expenses for services covered by contract or policy.

Request For Proposal (RFP) - request made to a dental discount plan for preliminary quote on group coverage.

Schedule of Benefits a listing of dental services and the maximum benefit amounts an insurer will pay for a given service. Specificity will vary by benefit plan.

Section 125 Plan - section 125 cafeteria plans are written benefit plans, maintained by companies for benefit of employees. The plan must meet all legal requirements of section 125 for employers to enjoy tax benefits associated with these type dental benefit plans.

Self-Funding - a program providing employees benefits financed entirely by employer, as opposed to purchasing dental-health benefits from a insurance carrier.

Staff Model Office - dental benefit plans term office model, often used by DHMO's. Dentists are employees of this type plan, and are paid a fixed salary regardless of the amount of care they provide.

Table Of Allowances (TOA)- a method used by insurance companies to determine what fees they will allow a dentist to charge. Unlike a UCR table, the TOA states a specific dollar figure allowed for each procedure.

Third Party Administrator (TPA) - an individual or company processing and paying claims for self-funded dental benefit plans. The TPA undertakes no financial risk for claims. A TPA typically charges a fee for these services.

Third Party Payor - dental benefit plan paying for dental services.

Usual, Customary And Reasonable Fee (UCR) - a price listing of dental procedures developed by a dental insurance companies. Listing dictates maximum reimbursements allowed to dentist for covered services, usually based on a percentage of area providers normal fees.

Usual Fee - most frequently charged fee for a given service.

Utilization - the extent to which members of a covered group uses a program over a stated period of time.

Vendors - dental benefit plans/companies that provide coverage or discounts to you, the patient.

Veneer - an esthetic, or tooth colored material put on the surface of a tooth, primarily for cosmetic reasons. Veneers can be made of acrylic resin or porcelain, and may be placed directly on the tooth.

* W,X,Y,Z - No definitions.

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