Allowable Charges: The maximum dollar amount on which benefit payment is based for each dental procedure.
Beneficiary: A person who receives benefits under a dental benefit contract. Dental Insurance
Benefit: The amount payable by a third party toward the cost of various covered dental services or the dental service or procedure covered by the plan.
Benefit Booklet: A booklet or pamphlet provided to the subscriber which contains a general explanation of the benefits and related provisions of the dental benefit program. Also known as a “Summary Plan Descriptions.”
Capitation: A capitation program is one in which a dentist or dentists contract with programs’ sponsor or administrator to provide all or most of the dental services covered under the program to subscribers in return for payment on a per-capita basis.
Certificate Holder: The person, usually the employee or responsible party, who represents the family unit covered by the dental benefit program; other family members are referred to as “dependents.” Dental Insurance
Closed Panel: A closed panel dental benefit plan exists when patients eligible to receive benefits can receive them only if service are provided by dentists who have signed an agreement with the benefit plan to provide treatment to eligible patients. As a result of the dentist reimbursement methods characteristic of a closed panel plan, only a small percentage of practicing dentists in a given geographical area are typically contracted by the plan to provide dental services.
Contract Dentist: A practitioner who contractually agrees to provide services under special terms, conditions and financial reimbursement arrangements.
Contract Fee Schedule Plan: A dental benefit plan in which participating dentists agree to accept a list of specific fees as the total fees for dental treatment provided.
Coverage: Benefits available to an individual covered under a dental benefit plan.
Covered Person: An individual who is eligible for benefits under a dental benefit program.
Covered Services: Services for which payment is provided under the terms of the dental benefit contract. Dental Insurance
Dental Benefits Organization: Any organization offering a dental benefit plan. Also known as dental plan organization.
Dental Benefit Plan: Entitles covered individuals to specified dental services in return for a fixed, periodic payment made in advance of treatment. Such plans often include the use of deductibles. coinsurance, and/or maximums to control the cost of the program to the purchaser.
Dental Benefit Program: The specific dental benefit plan being offered to enrollees by the sponsor.
Dental Insurance: A plan that financially assists in the expense of treatment and care of dental disease and accidents to teeth.
Dental Prepayment: A method of financing the cost of dental services prior to their receipt.
Dependents: Generally spouse and children of covered individual, as defined by terms of the dental benefit contract.
Eligibility Date: The date an individual and/or dependents become eligible for benefits under a dental benefit contract. Often referred to as effective date.
Enrollee: Individual covered by a benefit plan.
Exclusions: Dental services not covered under a dental benefit program.
Expiration Date: 1) the date on which the dental benefit contract expires.
2) The date and individual cease to be eligible for benefits. Dental Insurance
Fee-for-Service: A method of paying practitioners on a service-by-service rather than a salaried or capitated basis.
Fee Schedule: A list of the charges established or agreed to by a dentist for specific dental services.
Health Maintenance Organization (HMO): 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. An organized system of health care delivery that provides comprehensive care to enrollees through designated providers. Enrollees are generally assessed a monthly payment for health care services and may be required to remain in the program for a specified amount of time.
Indemnity Plan: A dental plan where a third-party payer provides payment of an amount for specific services, regardless of the actual charges made by the provider. Payment may be made either to enrollees or, by assignment, directly to dentists. Schedule of allowances, table of allowances, or reasonable and customary plans are examples of indemnity plans.
Insurer: An organization that bears the financial risk for the cost of defined categories or services for a defined group of beneficiaries.
Insured: Person covered by the program. Dental Insurance
Liability: An obligation for a specified amount or action.
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.
Managed Care: Refers to a cost containment system that directs the utilization of health benefits by:
a. restricting the type, level and frequency of treatment;
b. limiting the access to care; and
c. controlling the level of reimbursement for services.
Maximum Allowance: The maximum dollar amount a dental program will pay towards the cost of a dental service as specified in the program’s contract provisions, e.g., UCR. Table of Allowances.
Maximum Benefit: The maximum dollar amount a program will pay toward the cost of dental care incurred by an individual or family in a specific period, usually a calendar year.
Maximum Fee Schedule: A compensation arrangement in which a participating dentist agrees to accept a prescribed sum as the total fee for one or more covered services.
Member: An individual enrolled in a dental benefit program.
Necessary Treatment: A necessary dental procedure or service as determined by a dentist, to either establish or maintain a patient’s oral health. Such determinations are based on the professional diagnostic judgment of the dentist, and the standards of care that prevail in the professional community. Dental Insurance
Noncontributory Program: A method of payment for group coverage in which all of the monthly premium for the program is paid by the sponsor.
Nonduplication of Benefits: This may apply if a subscriber is eligible for benefits under more than one plan. A dental benefit contract provision relieving the third-party payer of liability for cost of services if the services are covered under another program. Distinct from a coordination of benefits provision, because reimbursement would be limited to the greater level allowed by the two plans, rather than a total of 100% of the charges. Also referred to as “benefit-less-benefit” or “carve-out”.
Nonparticipating Dentist: Any dentist who does not have a contractual agreement with a dental benefit organization to render dental care to members of dental benefit program.
Open Enrollment: The annual period in which employees can select from a choice of benefit programs.
Participating Dentist: Any dentist who has a contractual agreement with a dental benefit organization to render care to eligible persons.
Point of Service: arrangements in which patients with a managed care dental plan have the option of seeking treatment from an “out-of-network” provider. The reimbursement for the patient is usually based on a low table of allowances, with significantly reduced benefits than if the patient had selected an “in-network” provider. Dental Insurance
Preauthorization: Statement by a third-party payer indicating that proposed treatment will be covered under the terms of the benefit contract.
Precertification: Confirmation by a third-party payer of a patient’s eligibility for coverage under a dental benefit program.
Predetermination: An administrative procedure that may require the dentist to submit a treatment plan to the third party before treatment is begun. The third party usually returns the treatment plan indicating one or more of the following: patient’s eligibility, guarantee of eligibility period, covered services, benefit amounts payable, application of appropriate deductibles, co-payment and/or maximum limitation. Under some programs. predetermination by the third party is required when covered charges are expected to exceed a certain amount, such as $200.
Pre-existing Conditions: Oral health condition of an enrollee which existed before his/her enrollment in a dental program.
Preferred Provider Organization (PPO): A formal agreement between a purchaser of a dental benefit program and a defined group of dentists for the delivery of dental services to a specific patient population, as an adjunct to a traditional plan, using discount fees for cost savings.
Premium: The amount charged by a dental benefit organization for coverage of a level of benefits for a specified time.
Prepaid Dental Plan: A method of financing the cost of dental care for a defined population, in advance of receipt of services.
Prevailing Fee: Term used by some dental benefit organizations to refer to the fee most commonly charged for a dental service in a given area.
Preventive Dentistry: Refers to the procedures in dental practice and health programs which prevent the occurrence of oral diseases.
Purchaser: Program sponsor, often employer or union, that contracts with the dental benefit organization to provide dental benefits to an enrolled population. Dental Insurance
Quality Assessment: The measure of the quality of care provided in a particular setting.
Quality Assurance: The assessment or measurement of the quality of care and the implementation of any necessary changes to either maintain or improve the quality of care rendered.
Reasonable and Customary (R&C) Plan: A dental benefit plan that determines benefits based only on “Reasonable and Customary” fee criteria.
Reasonable Fees: The fee charged by a dentist for a specific dental procedure that has been modified by the nature and severity of the condition being treated and by any medical or dental complications or unusual circumstances, and therefore may differ from the dentist’s “usual” fee or the benefit administrator’s “customary” fee.
Reimbursement: Payment made by a third party to a beneficiary or to a dentist on behalf of the beneficiary, toward repayment of expenses incurred for a service covered by the contractual arrangement.
Schedule of Allowances: A list of covered services with an assigned dollar amount that represents the total obligation of the plan with respect to payment for such services, but does not necessarily represent the dentist’s full fee for that service.
Schedule of Benefits: A listing of the services for which payment will be made by a third-party payer, without specification of the amount to be paid.
Subscriber: The person, usually the employee, who represents the family unit in relation to the dental benefit program. This term is most commonly used by service corporation plans. Dental Insurance
Surcharge: A stated dollar amount paid to the dentist by the beneficiary, in addition to other reimbursement received by third-party payer(s).
Table of Allowances: A list of covered services with an assigned dollar amount that represents the total obligation of the plan with respect to payment for such services, but does not necessarily represent the dentist’s full fee for that service.
Termination Date: 1) the date on which the dental benefit contract expires.
2) The date and individual cease to be eligible for benefits.
Third Party: The party to a dental benefit contract that may collect premiums, assume financial risk, pay claims, and/or provide other administrative services
Third-Party Administrator (TPA): Claims payer who assumes responsibility for administering health benefits plans without assuming any financial risk. Some commercial insurance carriers and Blue Cross/ Blue Shield plans also have TPA operations to accommodate self-funded employers seeking administrative services only (ASO) contracts.
Third-Party Payer: An organization other than the patient (first party) or health care provider (second party) involved in the financing of personal health services.
Usual, Customary and Reasonable (UCR) Plan: A dental benefit plan that determines benefits based on “Usual, Customary, and Reasonable: fee criteria.
Usual Fee: The fee that an individual dentist most frequently charges for a given dental service.
Utilization: 1) The extent to which the members of a covered group use a program over a stated period of time; specifically measured as a percentage determined by dividing the number of covered individuals who submitted one or more claims by the total number of covered individuals. 2) An expression of the number and types of services used by the members of a covered group over a specified period of time. Dental Insurance
Waiting Period: The period between employment or enrollment in a dental program and the date when a covered person becomes eligible for benefits.