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Glossary of Terms
Access
The availability of care to a patient.
Actual Charge
The actual amount charged by a provider for services.
Adjudication
Processing a claim to determine proper payment.
Age Limit
Minimum and maximum ages below and above which a benefits company will not accept applications or may not renew policies.
Allowable Charges
The maximum dollar amount a benefits plan will pay for a procedure.
Amalgam
A silver filling.
Ancillary Services
Services, other than those a provider performs, such as laboratory work, x-rays, and anesthesia.
Anesthesia
See General Anesthesia, Intravenous Sedation / Analgesia, Local Anesthesia, Non-Intravenous Conscious Sedation, or Regional Anesthesia.
Application
A signed statement a benefits company requests that is used to decide whether or not to issue a policy.
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Balance Billing
When subscribers are billed for the difference between what the insurer pays and the fee that the provider normally charges.
Benefits
The amount a benefits company will pay.
Benefit Booklet
A booklet or pamphlet given to the subscriber that contains a general explanation of the benefits. Also known as a Summary Plan Descriptions.
Benefit Plan
A plan that gives covered individuals services in return for a premium paid in advance. Such plans often include deductibles, coinsurance, and/or maximums.
Bilateral
Both the right and left sides.
Billed Claims
The amount submitted by a provider for services provided to a covered individual.
Bitewings
X-rays used to reveal several upper and lower teeth as patients bite down on the x-ray film.
Bleaching
A cosmetic dental procedure that whitens teeth using a bleaching solution.
Bonding
The white dental material that is applied to a tooth to change its shape and/or color. Bonding also refers to how a filling or some fixed partial dentures are attached to teeth.
Bridge
See Fixed Partial Denture and/or Removable Partial Denture. See also Pontic.
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Calendar Year
The period beginning January 1 through December 31 of the same year.
Cap
see Crown.
Capitation
Fees paid to providers based on the number of patients they serve on behalf of a benefits plan.
Caries
Commonly used term for tooth decay.
Carve Out
See Nonduplication of Benefits.
Cavity
Tooth decay.
Cementation
Placing a fixed crown or bridge with a dental cement.
Certificate of Coverage
A description of the benefits included in a benefits company's plan. The certificate of coverage is required by state law and explains the coverage provided under the contract issued to the employer.
Certificate of Insurance
A statement of coverage issued to an individual insured under a group contract that outlines members' benefits.
Claim
Information submitted by a provider or covered person for reimbursement for services or materials.
Claims Review
Review of a claim before reimbursement is made to the provider or subscriber.
Closed Panel
With a closed panel, patients are eligible to receive benefits only if service is provided by providers who have signed an agreement with the benefit plan to provide treatment to eligible patients.
COBRA
A law that requires employers to offer continued benefits coverage to employees who have had their benefits coverage terminated.
Coinsurance
A percentage of the costs of services a patient pays. This is a characteristic of indemnity insurance, POS, and PPO plans.
Composite
A white filling.
Contract Provider
A provider who agrees to provide services under special terms, conditions, and reimbursement arrangements.
Contract Fee Schedule Plan
A benefit plan in which participating providers agree to accept set fees for treatment.
Contract Year
The period of time from the effective date of the contract to the expiration date of the contract.
Coordination of Benefits (COB)
The provision that limits benefits for members with multiple benefits plans.
Co-payment, Co-pay
A specific fee paid by the subscriber for a specific service.
Coverage
Benefits of a benefit plan.
Covered Entity
Under HIPAA, this is a health plan, a health care clearinghouse, or a health care provider who transmits any health information in electronic form in connection with a HIPAA transaction.
Covered Person
An individual who meets a health plan's eligibility requirements and for whom premium payments are paid.
Covered Expenses
Expenses incurred by a covered person who qualifies for reimbursement under the terms of a policy.
Covered Services
Services for which payment is provided under the terms of a policy.
Credentialing
Approving a provider to participate in a benefit plan.
Crown
Anatomical Crown: That portion of tooth normally covered by, and including, enamel
Abutment Crown: Artificial crown to support a dental device used to replace a missing tooth
Artificial Crown:A crown that covers or replaces most of or the whole of the crown of a tooth
Clinical Crown: That portion of a tooth not covered by supporting tissues.
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D.D.S., D.M.D.
Academic degrees for dental practice.
Date of Service
The date that the service was provided.
Debridement
Removing foreign matter or dead tissue.
Decay
The decomposition of tooth structure.
Deductible
The amount of covered charges the member pays before benefits are paid.
Deductible Carry Over Credit
Charges applied to the deductible for services during the last months of a calendar year that may be used for the next year's deductible.
Dental Health Maintenance Organization (DHMO)
A legal entity that accepts responsibility and financial risk for providing specified services to members during a defined period of time at a fixed price. It is an organized system of care delivery that provides comprehensive care to enrollees through designated providers.
Dental Coverage
A plan that provides financial assistance for the expense of prevention, treatment, and care of dental disease.
Dental Prosthesis
An artificial device that replaces one or more missing teeth.
Denture
An artificial substitute for natural teeth and adjacent tissues.
Denture Base
The part of the denture that holds artificial teeth and fits over the gums.
Dependent
An individual who is eligible for benefits through a spouse, parent, or other family member.
DHMO
See Dental Health Maintenance Organization.
Digital X-Ray
X-rays that are seen immediately on a computer screen after exposure.
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Effective Date
The date on which benefits under a policy begins.
Eligibility Date
The date on which an individual member of a group becomes eligible to apply for benefits under the benefit plan.
Eligibility Period
A specified length of time, following the eligibility date during which an individual member of a particular group will remain eligible to apply for benefits under a benefit plan without evidence of insurability.
Eligible Dependent
A dependent of a covered person (spouse, child, or other dependant) who meets all requirements specified in the contract to qualify for coverage and for whom premium payment is made.
Eligible Employee
An employee who meets the eligibility requirement specified in the group contract to qualify for coverage.
Eligible Expenses
The lower of the reasonable and customary charges or set service fees for dental or vision services and supplies that are covered under a benefit plan.
Employee Contribution
The portion of the premium paid by the employee.
Employer Contribution
The portion of the cost of a benefit plan an employer pays.
Endodontist
A dental specialist who limits his/her practice to treating disease and injuries of tooth pulp.
Enrollee
An individual covered by a benefit plan.
Enrollment Booklet
A booklet or pamphlet provided to the subscriber that contains a general explanation of the plan's benefits. Also known as a "Summary Plan Descriptions."
Enrollment Period
The amount of time an employee has to sign up for a plan with employer contributions.
EPO
See Exclusive Provider Organization.
Evaluation
Periodic Oral Evaluation: An evaluation performed to determine any changes in the patient's oral health since a previous comprehensive or periodic evaluation.
Limited Oral Evaluation: An evaluation limited to a specific oral problem.
Comprehensive Oral Evaluation: A thorough evaluation and recording of the hard and soft tissues inside and outside of the mouth, including the evaluation and recording of the patient's dental history.
Comprehensive Periodontal Evaluation: An evaluation of periodontal conditions, probing and charting, evaluation, and recording of the patient's dental history.
Re-Evaluation: An assessment a previously existing condition.
Exclusions
Services not covered under a benefit program.
Exclusive Provider Organization (EPO)
People who belong to an EPO must receive their care from affiliated providers, and services rendered by unaffiliated providers are not reimbursed.
Expiration Date
The date on which the dental benefit contract expires, also the date an individual ceases to be eligible for benefits.
Explanation of Benefits (EOB)
The statement sent to a subscriber by their benefits company listing services provided, amount billed, eligible expenses, and payment made by the company.
Extraction
The removal of a tooth or tooth parts.
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Fee for Service
Traditional provider reimbursement in which the doctor is paid according to the service performed.
Fee Schedule
A list of the charges for specific services to which a provider agrees.
Filling
Restoring of lost tooth structure by using materials such as metal, plastic, or porcelain.
Fixed Appliances
Braces.
Fixed Partial Denture
An artificial device that replaces one or more missing teeth that is cemented to teeth, attached to teeth or implanted to the space next to the missing tooth or teeth.
Fluoride
A natural substance known to prevent tooth decay.
Full-Mouth X-Rays
A combination of 14 x-rays that reveals all the teeth and the bone around them.
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General Anesthesia
A controlled state of unconsciousness, accompanied by a partial or complete loss of reflexes.
Gingiva
The gums.
Gingivitis
Inflammation of the gums without loss of connective tissue.
Gingivectomy
The excision or removal of part of the gums.
Gingivoplasty
Surgical procedure to reshape the gums.
Grace Period
A specified period after a premium payment is due.
Grievance Procedure
A procedure that allows a member of a plan or a provider of benefits to express complaints and seek solutions.
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Health Care Providers
A provider of services, such as a dentist.
HIPAA
The "Health Insurance Portability and Accountability Act of 1996." HIPAA includes four key components: Electronic Transactions, Portability, Privacy, and Security.
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Identification Card
A card given to each person covered under a benefit plan.
Impacted Tooth
A tooth that is positioned against another tooth, bone, or soft tissue.
Implant
An artificial device specially designed to be placed surgically within or on the jawbones to replace teeth.
Implantation
Placement of an artificial or natural tooth into bone.
Impression
A mold of a tooth or teeth.
In-Force Business
Coverage for which premiums are being paid or for which premiums have been fully paid.
In-Network
Providers who have contracts with a benefit plan to provide services at a set rate.
Incurred Claims
Incurred claims equal the claims paid during the policy year plus claim reserves.
Indemnity Insurance
Traditional fee-for-service coverage in which providers are paid according to services performed.
Inlay
A dental restoration made outside of the oral cavity to match the form of a prepared cavity that is then placed in the tooth.
Insurer
An organization that bears the financial risk for a group for the cost of services and materials.
Insured
People covered by a benefits plan.
Intravenous Sedation/Analgesia
A medically controlled state of unconsciousness while maintaining the patient's airway, reflexes, and the ability to respond to stimulation or verbal commands. It includes a sedative and/or pain reducing IV and monitoring.
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Lapse
Termination of a policy for failure to pay the premium.
Liability
An obligation for a specified amount or action.
Limitations
Restrictive conditions stated in a benefit contract, such as age, length of time covered, and waiting periods, which affect an individual's or group's coverage.
Local Anesthesia
Anesthesia, such as Novocaine, that temporarily numbs an area of the body.
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Malocclusion
Improper alignment of biting or chewing surfaces of upper and lower teeth.
Managed Care
A health care system under which providers are organized into a network in order to manage the cost, quality, and access to health care. Managed care organizations include Preferred Provider Organizations (PPOs) and Dental Health Maintenance Organizations (DHMOs).
Maximum Allowance
The maximum dollar amount a benefits program will pay towards the cost of a service as specified in the program's contract provisions, (e.g. Usual, Customary, and Reasonable [UCR] Table of Allowances).
Maximum Benefit
The maximum dollar amount a benefit program will pay toward the cost of care for an individual or family in a specific period.
Maximum Fee Schedule
An arrangement in which a participating provider agrees to accept a set amount as the total fee for one or more covered services.
Member
An individual enrolled in a benefit program.
Molar
Back teeth.
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Necessary Treatment
A necessary procedure or service to maintain a patient's health.
Network
A defined group of providers.
Non-contributory
Employee benefit plans paid for by the employer. One hundred percent of the eligible employees must participate.
Non-duplication of Benefits
A part of a contract that relieves a third-party payer of liability for cost of services, if the services are covered under another program. Non-duplication of Benefits is distinct from Coordination of Benefits because reimbursement is limited to the larger benefit allowed by the two plans, rather than a total of 100 percent of the charges. Also referred to as Benefit-Less-Benefit or Carve Out.
Non-Intravenous Conscious Sedation: A medically controlled unconsciousness that maintains the patient's airway, reflexes, and the ability to respond to stimulation or verbal commands. It is given with a sedative and/or analgesic agent(s) by a method other than IV.
Non-participating Provider
Any provider who is not a part of the network of a benefit plan.
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Occlusion
Any contact between biting or chewing surfaces of upper and lower teeth.
Office Visit
Services provided in the provider's office.
Open Access
See Open Panel.
Oral Surgeon
A dental specialist whose practice is limited to the diagnosis, surgical, and treatment of diseases, injuries, deformities, and defects of the oral region.
Orthodontist
A dental specialist whose practice is limited to the treatment of misaligned teeth and their surrounding structures.
Out-of-Network
Providers who are not a part of a benefit plan's network.
Out-of-Pocket Costs
The amount the covered person must pay out of his or her own pocket for services and materials. This includes such things as coinsurance, deductibles, etc.
Out-of-Pocket Maximum
The total payments that must be paid by a covered person (i.e. deductibles and coinsurance).
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Paid Claims
Amounts paid to providers.
Palliative
Treatment that relieves pain.
Partial Denture
An artificial device that replaces missing teeth.
Participating Provider
Any provider who is a member of a benefit plan's network.
Pediatric Dentist
A dental specialist whose practice is limited to treatment of children from birth through adolescence.
Pedodontist
See Pediatric Dentist.
Peer Review
Review of health care provided by providers by professionals with training equal to the staff that provided the treatment.
Pended Claims
Claims that have been submitted but not yet paid.
Periodontal
Pertaining to the supporting and surrounding tissues of the teeth.
Periodontal Abscess
An infection in the gum pocket that can destroy hard and soft tissues.
Periodontal Disease
Inflammation of the gums and/or periodontal membrane of the teeth.
Periodontist
A dental specialist whose practice is limited to the treatment of diseases of the supporting and surrounding tissues of the teeth.
Periodontitis
Inflammation and loss of the connective tissue of the supporting or surrounding tooth structure.
Plaque
A soft, sticky substance, composed largely of bacteria, that accumulates on teeth.
Point-of-Service Plans
Plans that permit insured persons to choose providers outside the plan but that are designed to encourage use of network providers.
Policy
The legal document a benefits company issues to the policyholder, which outlines the conditions and terms of the benefits, also called the policy contract or the contract.
Policy Term
The period for which a benefits policy provides coverage for eligible employees.
Pontic
An artificial tooth used in a bridge to replace a missing tooth.
Portability
A component of HIPAA that provides for the protection of benefits coverage for workers and their families when they change or lose their jobs and that prevents discrimination against employees and their families due to preexisting medical conditions.
Post
A device like a pin that is fitted and cemented within a prepared root canal that strengthens material that restores the affected area and/or a crown.
PPO
See Preferred Provider Organization.
Preauthorization
A statement by a third-party payer indicating that proposed treatment will be covered under the terms of the benefit contract.
Pre-certification
A third-party payer's confirmation of a patient's eligibility for coverage under a benefit program.
Pre-determination
A request that may require the provider to submit a treatment plan to the third-party payer before treatment is begun.
Pre-existing Conditions
An enrollee's health condition that existed before his/her enrollment in a benefit program.
Preferred Provider
Providers who contract to provide health services to persons covered by a particular health plan.
Preferred Provider Organization
PPOs are managed care organizations that offer certain methods to deliver services, such as networks of providers. Under a PPO benefit plan, covered individuals retain the freedom to choose providers but are given financial incentives (i.e. lower out-of -pocket costs) to use the preferred provider network.
Premium
The payment for a benefit plan.
Prepaid Dental Plan
A method of financing the cost of dental care for a group in advance of receipt of services.
Preventive Care
Care with an emphasis on preventing health problems before they occur.
Primary Coverage
Coverage that pays expenses first whether or not there is any other coverage. See Coordination of Benefits.
Prophy
See Prophylaxis.
Prophylaxis
A scaling and polishing procedure performed to remove plaque, calculus, and stains.
Prosthesis
An artificial replacement of any part of the body.
Prosthodontist
A dental specialist whose practice is limited to the restoration of the natural teeth and/or the replacement of missing teeth with artificial substitutes.
Protected Health Information ("PHI")
Protected Health Information is made up of two components, Health Information and Individually Identifiable Health Information. Health Information is information that relates to the past, present, or future health of the individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care. Individually Identifiable Health Information is information is information that can be used to identify the individual, such as a name or social security number.
Provider
A health professional that provides health care services.
Pulpectomy
Complete removal of pulp tissue from the root canal.
Pulpotomy
Surgical removal of a portion of tooth pulp to maintain the health of the remaining portion of the tooth.
Purchaser
A benefit plan sponsor, often an employer or a union, that contracts with the benefit organization to provide benefits to a group.
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Quadrant
The dental term for the division of the jaws into four parts. Each quadrant generally contains five to eight teeth.
Quality Assessment
The measure of the quality of care.
Quality Assurance
The assessment of the quality of care and any necessary changes to either maintain or improve the quality of care.
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Radiograph
X-ray.
Rebase
To replace the denture base.
Re-credentialing
Renewing approval of a provider to provide or participate in a benefit plan.
Referral
Permission to consult another doctor.
Regional Anesthesia
See Local Anesthesia.
Reimbursement
Payment made by a third party to a subscriber or provider for expenses of services or materials.
Reline
To resurface the side of a denture to make it fit more securely.
Removable Appliance
Removable orthodontic devices to cause simple movements of one or several teeth.
Removable Partial Denture
An artificial device that replaces of one or more missing teeth that a patient can remove.
Renewal
Continuing coverage under a policy beyond its original term with the insurer's acceptance of a premium for a new policy term.
Retainer
Orthodontic Retainer: A device to stabilize teeth following orthodontic treatment.
Prosthodontic Retainer: A part of a fixed partial denture that attaches a bridge to the adjacent tooth or implant.
Rider
A document which changes a policy or certificate. It may increase or decrease benefits (i.e. coverage for orthodontia).
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Scaling
Removal of plaque, calculus, and stains from teeth.
Schedule of Benefits
A listing of the services for which a benefit plan will pay.
Sealants
Plastic placed on the biting surfaces of back teeth to prevent cavities.
Section 125 Plan
A plan that provides flexible benefits that qualifies under the IRS code to allow employee contributions with pre-tax dollars.
Specialist
A provider who has been specially trained in and practices a specific type of care other than general practice.
Subscriber
The person, usually the employee, who represents a family in a benefit program.
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Temporary Removable Denture
An interim, artificial device designed for use over limited period of time.
Temporomandibular Joint (TMJ)
The hinge between the base of the skull and the lower jaw.
Temporomandibular Joint Dysfunction
Abnormal functioning of temporomandibular joint.
Termination Date
The date on which the benefit contract expires or the date an individual ceases to be eligible for benefits.
Time Limit
The period of time during which a claim must be filed.
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Usual, Customary, and Reasonable (UCR)
The commonly charged fees for services within a geographic area.
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Veneer
In the construction of crowns or bridges, a layer of tooth-colored material.
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