capline dental services

Glossary of Dental Insurance Terms

Terms Definition
Adjudication 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.
Administrative costs It includes general administrative services such as billing, claims processing, and other expenses.
Allowable charge 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.
Approved amount It’s the total cost that needs to be paid by you (patient) and member company.
Balance billing The difference between the total cost of the services a patient is charged for and the amount patient’s insurance plan pays.
Beneficiary A person who is eligible to receive insurance benefits.
Benefit summary It’s the summary of your dental insurance plan including deductibles, maximums, co-payment percentages, and non-covered services.
Benefit year 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 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.
Carrier A carrier is an insurance company that pays the claims and collects premiums from its members or subscribers.
Cdt codes (current dental terminology) CDT codes are standard dental codes required for e-dental claims. These codes are managed by American Dental Association (ADA) under HIPAA.
claim form 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.
Claims reimbursement The amount an insurance company or carrier pays to a dentist or enrollee (you) based on the claims submitted against a particular service provided.
Claims review It’s the process to check/review the details of a claim submitted before making a reimbursement. It’s basically a monitoring system and the purpose is to validate the accuracy and appropriateness of the provided services.
Closed panel Under closed panel or closed network, a patient can visit only in-network dentist to receive plan benefits.
Cobra COBRA stands for Consolidated Omnibus Budget Reconciliation Act. It’s a federal law that allows you to continue with your existing dental or medical coverage for a limited period in case of job loss, other qualifying event (usually 18 months after the final day of employment). It goes up to 29 months in case of disablity.
Coinsurance The percentage of the cost of services paid by the patient.
Coordination of benefits (cob) It’s a provision in the contract when a person is covered under more than one dental insurance plan. A child usually gets dual coverage by parents’ plans. The two plans are coordinated to ensure that not more than 100% covered expense is paid. To limit the coverage further, another provision named non-duplication of benefits is also there.
Copayment Copay is a fixed amount for a covered service, paid by a patient to the provider of service before receiving the service.
Cost sharing Some portion of the cost you need to pay as a member of a health insurance plan in order to receive services.
Covered services The services covered under your insurance plan.
Credentialing The process of reviewing documentation related to a dentist including verification of licenses, specialty certification (if applicable), malpractice insurance, state and local licensing board actions, infection control procedures, and Occupational Safety and Health Administration (OSHA) requirements.
Dds/dmd DDS stands for Doctor of Dental Surgery. DMD stands for Doctor of Dental Medicine.
Deductible Deductible is the amount paid out of pocket by the policy holder before an insurance starts paying.
Delta dental plans association (ddpa) DDPA is an organization of Delta Dental member companies. It provides the Delta Dental System with national guidelines and support.
Dentist filed fees An in-network dentist’s submission of fees for common dental procedures to his/her practice and reported frequently on dental claims.
Department of health and human services (hhs) It’s the United States Department of Health and Human Services created to protect the health of the US citizens.
Department of managed health care (dmhc) DHMC is a regulatory body managing healthcare plans.
Diagnostic and preventative procedures The standard diagnostic and preventative procedures include x-rays, cleaning procedures, space maintainers, oral examinations, and flouride treatment.
Disallowance When an insurance company denies portions of the claimed amount, it’s called Disallowance. It can include coordination of benefits, services that are not covered, or amounts over the fee maximum.
Dual coverage It’s repetitive. Remove it.
Emergency services Immediately required dental services in order to relieve pain, bleeding, swelling, or required to avoid risk the patient’s health.
Employee contribution The portion or the part of the insurance premium paid by the employee.
Enrollee A person who has enrolled in an insurance plan to get dental services/benefits.
Explanation of benefits (eob) Explanation of Benefits, also known as Explanation of Review (EOR) is a document that explains the entire claim process to the dental practice and the patient.
Fee-for-service Under Fee for service reimbursement model, dentists are paid/remibursed a specified amount for each treatment they prescribe.
Fee schedule A fee schedule is a complete listing of fees used by Insurance to pay doctors or other providers.
General dentist A dentist who provides a full range of dental services.
Group It refers to a dental benefit customer, usually an employer or union.
Heath insurance portability and accountability act of 1996 (HIPAA) It’s a federal law that creates national standards to protect sensitive information pertaining to a patient’s health from being disclosed without his/her consent or knowledge.
HMO (health maintenance organization) A health maintenance organization (HMO) is a medical insurance group or structure that provides medical coverage to its members through a fixed network of healthcare providers for an annual fee.
In-network The term covers the dentists who participate or agree to provide their services under a particular plan.
Limitations/exclusions It refers to the services that are limited or excluded from a dental insurance plan. You are liable to pay for these services if you wish to receive them. These services are generally called optional services.
Maximum/ annual maximum/maximum benefit The maximum amount that a dental plan pays for the services a patient has received in a plan year or benefit year.
Medicaid Medicaid is a popular federal-state public health insurance program to help low-income families or individuals with medical costs including doctor visits, hospital stays, and other medical treatment costs.
Medicare Medicare is a federal medical or health insurance program for the U.S. citizens who are either 65 years and older, and disabled. Although there is a disability criteria. The program pays for hospitalization, for stays in skilled nursing facilities, for physician’s charges, and for some associated health costs.
Network A network of dentists or dental professionals who agree to provide their services to the members of particular dental plan.
National group/account A group with subscribers/members in more than one state.
Non-duplication of benefits It’s a provision in dual coverage cases which describes the way the secondary insurer calculates its pportion of payment.
Non-participating Dentists or dental professionals who do not participate in a particular dental program to provide their services are non-participating dentists.
Out-of-network It covers the dentists who have not participated or enrolled or agreed to be a part of a particular program/organization to provide their service to its members.
Out-of-pocket costs The cost that a patient pays which is not covered by his/her health insurance plan. It may include a copayment, a deductible, and any amount exceeding the plan’s maximum and optional services not covered by the plan.
Participating dentist It covers the dentists who participate or agree to provide their services under a particular program/plan. See In-network.
Preauthorization Preauthorization, also known as Prior authorization or prior approval, confirms a patient’s medical insurance coverage. Preauthorization allows a dentist to know if a particular treatment is covered by the patient’s insurance plan or not.
Predetermination/precertification The percentage of the recommended treatment covered by the insurance company. It includes other specifics like how the insurance company will pay a claim and when dentist or the patient will receive repayment.
Pre-existing A dental condition that existed before you enrolled in a dental insurance plan. Generally, a standard dental program do not exclude pre-existing conditions.
Preferred provider organization (ppo) A dental fee-for-service plan that allows you to visit any dentist of your choice and provides financial incentives if you visit any in-network dentists with low service fees.
Premium A premium is the monthly payment patients make to insurance companies for the dental insurance plans they have enrolled in.
Provider It refers to dentists and other dental care professionals who provide dental services.
Summary plan description (spd) It’s the booklet for the members of an ERISA (Employee Retirement Income Security Act of 1974) plan. ERISA is a federal law that sets minimum standards for health plans in private industry.
Table of allowance/schedule of allowance It’s the list of the maximum fees for each dental procedure that a specific dental program will pay.
Voluntary It refers to a dental plan in which you are allowed to enroll for coverage and pay more than 50% of the cost of the insurance plan.
Abscess It’s a type of dental infection that can cause pus inside the teeth or gums. This type of infection is usually the result of untreated cavity or injury.
Abutments It’s an element used to support a device or appliance replacing one or more teeth.
Alternate Benefit/LEAT Also known as LEAT or Least Expensive Alternate Treatment, it’s a provision in many dental insurance plans that states that the insurer will cover the least expensive treatment even if other better treatment is available for a patient.
Allowable Amount Also known as maximum allowable amount, it’s the highest amount payable for covered services.
Appeal An appeal is a form of request made to insurer to review denied or unpaid claims. Either you or your dentist can file an appeal to get reimbursed from insurance company.
Basic Services A category of dental services that includes fillings, extractions, root canals, and root planning. These services are also called Class II, Group II or Type B services.
Bitewings Images of upper and lower, front and back teeth used by dentists to check for decay, whether the teeth line up, bone loss from gum disease and infection. Bitewings are usually provided in sets of tooth or four x-rays.
Caries The common terms used for tooth decay.
Claim A request to get reimbursed under a dental insurance plan. A claim lists all the services rendered, itemized costs, date of service, etc. Payment is made using this information.
Consultation When you discuss or conult dental care or services you require with your dentist.
Contracted Rates The rates insurance companies pay their in-network dental professionals for the services they provide. These rates are mentioned in the insurers’ contract with providers.
Core buildup The process of replacing a part or all of the crown of a tooth whose purpose is to provide a base for retention of an indirectly fabricated crown.
Cost-sharing The portion of the cost you pay for the dental services you receive.
Covered Services The dental services, prescription drugs, and procedures, covered in your insurance plan. Any dental insurance plan does not cover everything. Even for the covered services, you may need to pay a deductible, co-payment or co-insurance.
Dental Assessment It’s the clinical examination used to find if there is any sign of dental diseases, malformation or injury. It helps a dental professional to recognize the appropriate and most suitable treatment for you or refer you to other dentist if required.
Dental Care Professional Any professional who is officially licensed or certified to provide dental services within the scope of that license or certification. It can include a dentist, dental hygienist, dental assistant, etc.
Dental Exclusive Provider Organization (DEPO) A dental plan similar to DHMOs and DPPOs. You can receive dental care only from in-network dentists. Only emergency services are covered in case of out-of-network dentists. Under a DEPO plan, you can visit specialists without a referral. However, the charges will be covered only if the specialist is in the network.
Dental Health Maintenance Organization (DHMO) A Dental HMO plan provides discounted dental care through a network of dentists. In detail, a DHMO plan is a type of managed care plan that offers comprehensive and less expensive dental care to individuals and families through a network of qualified dentists. A DHMO plan, also called a Capitation plan, is considered as least expensive dental insurance plan available.
Dental Implant A device specifically designed to be placed within or on the mandibular or maxillary bone through surgery. It’s a form of dental replacement.
Dental Indemnity Plan A dental indemnity plan allows you to visit any dentist of your choice as the plan has no pre-sepcified network of dentists. The plan usually has an annual deductible. It’s also called fee-for-service plan.
Dental Plan or Dental Insurance Policy You pay a monthly/yearly premium to a dental insurance company to be covered under a dental plan or denta insurance policy. The insurer pays some or all of your dental care costs in return. You may also need to pay other charges such as deductibles, co-pays, or co-insurance as part of the plan. DPPOs, DHMOs, DEPOs, DPOS, and Dental Indemnity Plans are some of the most common dental plans.
Dental Prepayment It’s a method of financing the cost of dental services before receiving them.
Fixed Prosthesis It’s a branch of the dental prosthesis that deals with the replacement / restoration of teeth by artificial substitutes that cannot be removed from the mouth.
Fixed-Removable Prosthesis It’s a treatment for restoration of the edentulous maxilla with implants.
Interim Prosthesis It’s defined as a fixed removable prosthesis, specially designed to improve esthetics, stabilization or function for a limited period of time.
Removable Prosthesis A type of dental device designed to replace multiple missing or damaged teeth. It’s also called dentures.
Dependents The people who are covered in your dental insurance plan are called Dependents. It can include your spouse, parents, children, etc. It’s generally defined by terms of your
dental plan.
Diagnostic and Preventive Services Your dental insurance plan pays for these services without deductibles or co-payments. These services usually include cleanings, x-rays, exams, fluoride treatment, sealants and space maintainers. Diganostic and Preventive Services are also known as Class I, Group I or Type A services.
Direct Reimbursement It’s a self-funded program in which you are reimbursed based on a percentage of dollars spent for dental services provided. It allows you to receive treatment from the dentist of your choice.
Discount Dental Plan or Dental Saving Plan Under a Discount Dental Plan or DDP, a group of dentists agrees to provide services at specified discounted charges. It’s not a dental insurance plan. You directly pay the discounted fee to the dentist for the services you receive.
Dry Socket It’s a dental condition that usually happens after extraction of a permanent tooth and blood clot fails to appear or dissolves before the wound is healed. It’s also known as alveolar osteitis.
Dual Choice Program The program allows you to enroll in either a traditional or an alternative dental benefit program.
Eligibility Date It’s the date you and your dependents are eligible for the plan benefits. It’s also known as effective date.
Expiration date The date beyond which you and your dependents are not eligible to avail the benefits of your dental insurance plan.
Extension of Benefits Extending eligibility for benefits for covered services as per your plan. It’s usually done to ensure the completion of treatment begun before the extended eligibility expires.
Extraction The process of removing a tooth.
Family Deductible Deductible for the combined expenses of all covered family members. Let’s assume that as per your family insurance plan, your family deductible is $100 and the individual deductible is $50. If two family members use their individual deductible, the limit of the family deductible is reached. So, other family members covered in the insurance plan who need dental treatment would not have any deductible for that calendar year.
Filling It’s the process of restoring lost tooth structure by using materials including metal, alloy, plastic or porcelain.
Flexible Spending Account It’s your employee repayment account which is primarily funded with your designated salary reductions. You and your dependents are paid for your health care. The funds in this account are considered as non-taxable benefit.
Gums The tissue that surrounds and support your teeth.
Health Savings Account (HSA) It’s a tax-advantaged savings account that you can open to pay for qualified dental and other medical expenses. You and your employer can put money in this account. The funds in this account belongs to you. The account goes with you if you change your job.
Impacted Tooth A tooth that is limited by bone or soft tissue from breaking through your gums.
Indemnity Dental Plan It’s repetitive. Remove it.
Indirect Restoration A restoration fabricated outside the mouth.
Insured Person covered by a dental insurance plan (you).
Least Expensive Alternate Treatment (LEAT) It’s repetitive. Remove it.
Major Services It’s a category of dental services that usually covers crowns, dentures, implants and oral surgery. Copayments or coinsurance is typically higher for these services. Also called Class III, Group III or Type C service.
Managed Care It’s a type of health insurance plans in contract with health care providers to receive services at reduced costs.
Maximum Allowable Amount It’s repetitive. Remove it.
Maximum Plan Benefit It’s the reimbursement level for a dental procedure regulated by a dental plan administrator.
Medically Necessary Care It refers to the essentially appropriate treatment and follow-up care as prescribed by dentist.
Non-covered charges The dental care charges/costs not covered by your insurer. For some covered services, the insurer is not responsible for the entire cost and you have to bear the charges not covered by your plan.
Non-Covered Services The dental care services not covered in your dental insurance plan. If you receive no-covered services, you will be liable to pay the entire treatment cost.
Nonduplication of Benefits It’s repetitive. Remove it.
Open Enrollment/Open Enrollment Period It’s the time of year when you can add, modify or cancel a dental insurance plan for the next year.
Open Panel A type of dental plan which allows you to receive dental care from any dentist because it allows any dentist or dental professionals to participate to offer their services. Open panel plans are also known as freedom of choice plans.
Out-of-network benefits The plan benefits you receive from the dentists don’t take your insurance plan.
Out-of-Pocket Maximum An out-of-pocket maximum is the most a health insurance policyholder will pay each year for covered healthcare expenses.
Overbilling Asking for higher than actual charges for a dental service is called overbilling.
Participating Provider It’s repetitive. Remove it.
Payer The one who is responsible for paying your claims. It can include your employer, government agency or insurance company.
Plan Year It’s repetitive. Remove it.
Point of Service (POS) Plan If you are a member of a POS plan, you can choose at the time of dental service whether you would go to an in-network provider or out-of-network provider.
Pre-existing condition A pre-existing condition is a health condition that existed prior to applying for health or life insurance.
Pretreatement Estimate It’s repetitive. Remove it.
Premedication Using medications before dental procedures is called Premedication.
Prepaid dental plan Prepaid dental plans are used to fund dental care/treatment costs in advance of services, for a limited/defined population.
Primary payer A primary payer is the insurer that pays a healthcare bill first.
Provider network A network of dentists and dental care professionals who agree to provide their dental care services to the members of a dental insurance plan under the terms of contract.
Qualified Dental Expenses The expenses that are allowed to be paid from Health Saving Accounts (HSAs) are Qualified Dental Expenses.
Self-funded plan A self-funded plan, also known as a self-insured plan, is a health plan where the employer assumes the risk for paying health claims as opposed to purchasing an insurance policy from an insurance carrier, where the insurer assumes the risk.
Usual, Customary and reasonable (UCR) The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service.