Dental Insurance Definitions

Allowable Charges
Most dental insurance plans will have a specified fee amount for any particular procedure or dental service. This specified amount will be the "allowable charges" for the procedure.

The person who receives the benefits (reimbursement) when the claim is submitted. Normally, this person will be the main person through whom the insurance is obtained.

The money you receive after making a claim

Benefit Booklet
Normally your reference guide to what is covered under your dental insurance and what is not. In most cases, these booklets will provide most of the information that you need, but if you need more details, you should contact your insurance company or your plan administrator (if you have your coverage through your job).

A capitation program is one in which a dentist or group of dentists agree to provide most or all services to the subscribers of a dental insurance plan, in return for payment on a per-capita basis. In this way, subscribers do not pay individual fees, since the dentist is being paid for the patient quota overall.

Certificate Holder
Normally the person who actually has the insurance. This person, usually the employee or responsible party, represents a family unit covered by the dental benefit program. Any other family members are referred to as "dependents."

Closed Panel
With a closed panel dental benefit plan, patients eligible to receive benefits can receive them only if service is provided by those dentists who have signed an agreement with the benefit plan. This is similar to some health insurance plans that limit a patient's access to doctors, based on doctors who are participating in the plan. With such plans, only a small percentage of practicing dentists in a given geographical area are typically part of the plan, therefore selection of a dental professional is limited.

Contract Dentist
Refers to a dentist who is under contract to a particular insurance plan. This is a practitioner who contractually agrees to provide services under special terms, conditions and financial reimbursement arrangements.

Contract Fee Schedule Plan
A special dental benefit plan where practitioners have agreed to a fee schedule. Therefore, when they participate in the plan, they agree to accept a certain fee as payment in full for the treatment provided.

This term refers to what you actually are covered for, under your dental plan. Remember that not all treatments may be covered. You should check your Benefit Booklet before receiving a treatment, if you are unsure.

Covered Person
This could be yourself (as the insured) or one of your dependents (including your spouse and children) that are included under the coverage of your dental plan.

Covered Services
These are services for which you can expect some level of reimbursement, under your dental plan. Not all plans reimburse for 100% of the cost of treatment; in fact, most don't. However, even if you receive 80 % reimbursement for a treatment or procedure, you are considered "covered".

Dental Benefits Organization
This is an organization offering a dental benefit plan. Such an organization may also be known as dental plan organization.

Dental Benefit Plan
A dental benefit plan entitles a covered person to specified dental services in return for a fixed, periodic payment. This payment is usually made in advance of treatment. Such plans often include the use of deductibles, coinsurance, or maximums (separately or in combination). These are a standard way that the folks offering the Dental Benefits Organization

Dental Benefit Program
This is the specific plan being offered. The program information will include what is covered, what is not and what levels of deductible, coinsurance and maximums are in place.

Dental Insurance
Dental insurance is just what it says. It's insurance for dental care costs. In general, it will financially assist in the expenses of treatment and care of either dental disease or accidents to the teeth. In return for this, you will pay premiums. These plans actually work in part by spreading the costs over a large group of people. Those requiring less dental service will actually "supplement" those requiring more.

Dental Prepayment
A method of paying for dental services. What you do is pay in advance.

Generally, if you are the insured person, your spouse and children will be considered "dependents" for purposes of the insurance. This does not mean that your spouse could not be working. It only means that you cover these other individuals through your policy.

Eligibility Date
Most dental insurance plans do not take effect immediately. There is a waiting period. So, the eligibility date is very important. It's the date that you and your family become eligible for benefits. This means that you will be covered under the plan. It's also often referred to as effective date.

The person who is enrolled in the dental insurance. In general, you will be called an "enrollee" until your benefits take effect. Then you will also be considered the "covered person".

As you might expect, exclusions refers to procedures or treatments that are not covered under your dental insurance plan.

Expiration Date
An expiration date in insurance generally refers to the date when your dental benefits expire or they refer to a date when you cease to be eligible. This could be for a number of reasons, such as changing employers or other conditions that would change your eligibility for your current insurance plan.

Fee Schedule
A list of charges for the services a dentist provides. Usually, a fee schedule is either established by the dental insurance plan, and to which all dentists in the plan must adhere, or it could be established by the dentist alone, if that dentist is not participating in that kind of dental insurance plan.

Health Maintenance Organization (HMO)
An HMO is an organization that accepts responsibility and financial risk for providing specified services. An HMO is a method of health care delivery that provides comprehensive care to covered persons through a system of designated providers. In most cases, if you belong to an HMO plan, you will be paying a monthly payment for health care services and you may also be required to remain in the program for a certain period of time.

Indemnity Plan
This is a dental plan where a third-party payer provides a specified payment for specific services, regardless of the actual charges for the service. The third-party is usually another insurance company. Payment may be directed either to the covered person or directly to the dentists (if the covered person so chooses).

The organization that provides you insurance! The insurer bears the financial risk for the cost of the services covered and normally spreads that risk over the group of beneficiaries, by means of premium payments.

That's you, the "covered person". You are the person who has contracted for insurance coverage and through whom your dependents have coverage.

Liability is the state of being responsible for some obligation or debt. In the case of insurance, the insurer will have a liability when you submit a claim for a covered service.

Limitations on coverage are just what you'd expect. Limitations can restrict the amount of coverage, length of time covered and may also refer to waiting periods. Limitations may also refer to the exclusion of certain benefits or services, or there may be limits to the extent or conditions under which certain services are provided. Always be sure to check your policy for limitations.

Managed Care
A model of health or dental care delivery. In most cases, dental plans turn to managed care as a cost containment strategy that will direct the use of health benefits in the following ways:

  1. restricting the type, level and frequency of specific treatments
  2. limiting the access to care
  3. controlling the level of reimbursement for services

Maximum Allowance
The maximum dollar amount that a dental program will pay towards the cost of a specific treatment or procedure. In most cases, maximums will be specified in your Benefits Booklet. You can find this information under the headings UCR or Table of Allowances.

Maximum Benefit
Maximum Benefit is different from Maximum Allowance. The maximum benefit is the total dollar amount an insurer will pay toward the cost of dental care for a specified period, usually a year. Therefore, you may have situations where the care you have actually received will exceed your maximum benefit. In this case, you will cease to be reimbursed for claims.

Maximum Fee Schedule
A maximum fee schedule is fundamentally a compensation arrangement for the dentist in which a participating dentist agrees to accept a certain sum as the total fee for a covered service. This is a situation that helps you to anticipate out of pocket costs with any allowed dental practitioner.

Another term used to describe a person who has enrolled in a dental benefit program.

Necessary Treatment
Treatment deemed by the dentist to be a necessary dental procedure or service, to either establish or maintain a patient's oral health. This will be based on the opinion of the dentists, as well as the standards of care in the dental profession.

Non-contributory Program
This is where you get a break. The sponsor of the program (usually your employer) pays for your (and your fellow employees) monthly dental insurance premium.

Non-duplication of Benefits
Non-duplication of benefits is a stipulation which will only apply if the subscriber could be eligible for benefits under more than one plan. What this really means is that you can't be paid for the same claim twice, even if you are submitting the claim to a separate payer, if this is a stipulation of your plan. Your reimbursement is limited to the greater level allowed between the two plans.

Non-participating Dentist
A dentist who is not part of the professionals under your plan. This would describe any dentist who does not have a contractual agreement with your dental benefit organization to provide dental care to members.

Open Enrollment
The period, usually once annually, when you can add dependents to your dental insurance plan. It is also usually the time when you can select from a choice of benefit programs.

Participating Dentist
A dentist that is part of the group of professionals providing services under your dental plan. It's a dentist you have access to. The term describes any dentist who has a contractual agreement with a dental benefit organization to provide dental care to enrollees.

Point of Service
This refers to a situation when you have sought care from a dental professional who is outside your network of providers, through you managed care dental plan. When you deal with a provider like this, you have to pay at "point of service". In other words, you pay for treatment yourself. Your reimbursement is usually based on a low table of allowances, with significantly reduced benefits. This approach is taken to encourage members to stay within the network.

A preauthorization is a statement by your insurer indicating that a proposed treatment (or plan of treatment) for a dental condition will be covered under your insurance. If you are in doubt, it's always worth the time to check, unless it is an emergency. Preauthorization can often be a smart thing to do!

Refers to confirmation of your eligibility for coverage. If you have any questions about when your coverage will take effect, it's worthwhile to call your plan administrator or insurance company directly, and be precertified.

In some insurance plans, the dentist must submit a treatment plan to the insurer before a longer or more complex treatment is begun. In some cases, there is a dollar limit over which a predetermination is required. Not all conditions will require this procedure; check your benefits booklet to be sure. Your insurance usually returns the treatment plan indicating one or more of the following: your eligibility, a guarantee of eligibility period, the services included in the treatment plan which are covered, benefit amounts payable, application of appropriate deductibles, co-payment and/or maximum limitation.

Pre-existing Conditions
Dental or oral health conditions that existed before you enrolled in your dental program. In some cases, pre-existing conditions will not be covered for a new enrollee.

Preferred Provider Organization (PPO)
A formal agreement between a dental plan program and a specific group of dentists who have signed up to deliver dental services to the client's of the dental plan. It has some similarities to an HMO in the sense that your choice of dentist is limited to those in the group.

The money that you pay in order to have dental insurance. Your premium is the amount charged to you by the dental benefit organization for your specific level of coverage. Most policies renew annually; in this case, premiums will be set annually.

Prepaid Dental Plan
A way of financing the cost of dental services. If you prepay, you are financing the cost of dental care in advance of actually receiving those services.

Prevailing Fee
The prevailing fee is the fee most commonly charged for a specific dental service in your area. Your dental benefit organization may use this term.

Preventive Dentistry
Taking care of your teeth in such a way as to avoid problems later. This term will be used to refer to procedures (like regular check ups) that help you to avoid or prevent the incidence of dental disease.

Here we are referring to the purchaser of the dental benefits plan. In most cases, this will be your employer or union, who has contracted with the dental benefit organization to provide insurance to the group.

Quality Assessment
The quality of care is almost as important to your dental benefit organization as it is to you. A quality assessment may be done from time to time to ensure the quality of care provided in a particular setting.

Quality Assurance
Quality assurance is also important both to your dental benefit organization and to you. Quality assurance is the assessment of the quality of care, including the implementation of changes as required, in order to maintain or improve services.

Reasonable and Customary (R&C)
A kind of dental insurance plan which will only reimburse based on "Reasonable and Customary" fee criteria. Your dentist or dental professional may charge more.

The payment you receive from your insurer. You may also be able to direct this payment directly to the dental professional that you received care from. The reimbursement may only cover a portion of the fee charged; you may be responsible for a portion due to deductible or other reason.

Schedule of Allowances
A list of covered services, with an assigned dollar value. This list will represent the total obligation of your insurance coverage. However, your dentist may charge more.

Schedule of Benefits
Slightly different than a Schedule of Allowances. A Schedule of Benefits is a listing of services for which you are covered. It does not specify the amount or fee level to which you are covered.

Another way to describe the enrollee or covered person. This is the person who represents the family unit in relation to the dental benefit program.

Perhaps best understood as the amount that you would have to pay, above and beyond the fee schedule of your insurer. You will have to pay the surcharge directly, even if you have directed your benefit amount to be paid directly to the dental professional.

Table of Allowances
A list of covered services with an assigned dollar amount. You will normally find it in your benefits booklet. This list represents the full payment that your insurer is willing to make for those services, whether or not it represents the dentist's full fee for any particular service.

Termination Date
The date when your coverage will expire or you 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. This is usually your insurer.

Third Party Administrator (TPA)
A claims payer who assumes responsibility for administering health benefits plans, but assumes no financial risk. Some commercial insurance carriers and Blue Cross/ Blue Shield plans also have TPA operations.

Third Party Payer
More commonly called your insurer. Technically, your insurer is a third party to the interaction between you, the patient (first party) and the health care provider (second party). The third party payer does just what you'd expect; they pay.

Usual, Customary and Reasonable (UCR) Plan
A plan where the benefits have been determined based on "Usual, Customary and Reasonable" fee criteria.

Usual Fee
The fee charged most frequently for a given dental service or procedure.

This term refers to how a program is being used. Utilization will measure:

  1. The extent to which the members use a program over a stated period of time;
  2. An expression of the number and types of services used by members over a specified period of time.
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