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.
The amount an insurance company or carrier pays to a dentist or enrollee (you) based on the claims submitted against a particular service provided.
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.
Under closed panel or closed network, a patient can visit only in-network dentist to receive plan benefits.
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.
The percentage of the cost of services paid by the patient.
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.
Copay is a fixed amount for a covered service, paid by a patient to the provider of service before receiving the service.
Some portion of the cost you need to pay as a member of a health insurance plan in order to receive services.
The services covered under your insurance plan.
