It’s the process of submitting a claim through multiple edits to ensure appropriate payment. When a claim is processed this way without any human interaction, it’s called auto-adjudication.
It includes general administrative services such as billing, claims processing, and other expenses.
Allowable charge is the fees on which plan deductibles, coinsurance, and maximums percentage are based, and dentists are reimbursed for the services rendered as per their agreement with insurer.
It’s the total cost that needs to be paid by you (patient) and member company.
It’s the total cost that needs to be paid by you (patient) and member company.
The difference between the total cost of the services a patient is charged for and the amount patient’s insurance plan pays.
A person who is eligible to receive insurance benefits.
It’s the summary of your dental insurance plan including deductibles, maximums, co-payment percentages, and non-covered services.
The year-long period during which a patient’s insurance plan provisions inclduing annual maximum, deductible, copay, etc. are applied. The beginning and the end date of a benefit year may vary from year to year. It’s also called plan year or benefit period.
Capitation is a type of a health care payment system in which a doctor or hospital is paid a fixed amount per patient for a prescribed period of time by an insurer or physician association.
A carrier is an insurance company that pays the claims and collects premiums from its members or subscribers.
CDT codes are standard dental codes required for e-dental claims. These codes are managed by American Dental Association (ADA) under HIPAA.
The claim form is used by a dentist or a patient to submit information regarding the dental services provided/received. A dentist is usually responsible to ensure that the information provided in the claim form is accurate. Based on the information provided in the form, an insurance company pays to the dentist or enrolle/beneficiary (you). The form can be submitted to a carrier or insurance company either on paper or electronically.
