Insurance glossary

Accreditation
A process of gauging the performance of organizations against a set of agreed upon standards or measures.

Administrator
A person who manages or directs a dental benefits program on behalf of the program's sponsor. The administrator can include an insurance company, third party or employer.

Administrative Services Only (ASO)
An arrangement under which an administrator processes claims for a fee and handles paperwork for a self-funded group. The employer assumes the risk for claims submitted.

Allowable Charge
The maximum dollar amount on which benefit payment is based for each dental procedure.

Alternate Treatment
If more than one type of service can be used to treat a dental condition, the administrator has the right to base benefits on the least expensive service which is in the range of professionally accepted standards of dental practice.

Anniversary
The beginning of an employer's benefit year.

Assignment of Benefits
A procedure whereby a beneficiary/patient authorizes the administrator of the program to forward payment for covered procedure directly to the treating dentist.

Audit
An examination of records or accounts to check their accuracy. A post-treatment record review or clinical examination to verify information reported on claims.

Balance Billing
Billing a patient for the difference between the dentist's actual charge and the amount reimbursed under the patient's dental benefits plan.

Beneficiary
The person who receives benefits under a dental benefit contract.

Benefit
The amount payable to the patient or member by a third party toward the cost of various covered dental services.

Benefit Plan Summary
The description or synopsis of employee benefits required by ERISA to be distributed to the employee.

Birthday Rule
Coordination of benefits regulation stipulating that the primary payer of benefits for dependent children is determined by the parents' dates of birth. Regardless of which parent is older, the dental benefits program of the parent whose date of birth falls first in a calendar year is considered primary. This rule varies by plan. Check your Benefit Plan Summary.

Cafeteria Plan
A benefit program in which you are given an amount of dollars or credits to be used toward a choice of benefit options. You select the benefits that best meet your needs from a menu of options offered by your employer. Also known as a Flexible Benefits Plan.

Calendar Year
January 1st through December 31st.

Capitation
A reimbursement method used primarily in Dental Health Maintenance Organizations (DHMO) where dentists provide covered dental services to members on a contract basis in return for a periodic per-capita payment.

Carrier
Refers to insurance company.

Certificate Holder
The person, usually the employee, who represents the family unit covered by the dental benefit program. Other family members are referred to as dependents.

Claim
A request for payment under a dental benefits plan. A claim form lists services rendered, the dates of services, and itemization of costs. Includes a statement signed by the beneficiary and treating dentist that services have been rendered. The completed form serves as the basis for payment of benefits.

Claim Review
The process of dentists reviewing specific claims for necessity and payment of benefits.

Claimant
Person who receives treatment. May be the patient or the certificate holder.

Claim Form
The form used to file for benefits under a dental benefits program.

Co-insurance
A provision of a dental benefits program by which the beneficiary shares in the cost of covered services, generally on a percentage basis. The percentage of a covered dental expense that a beneficiary must pay (after the deductible is paid). A typical co-insurance arrangement is one in which the third party pays 80% of the allowed benefit of the covered dental service and the beneficiary pays the remainder of the charged fee. See your summary plan description.

Complaint
A patient complaint is submitted in writing expressing a disagreement or grievance.

COBRA (Consolidated Omnibus Budget Reconciliation Act)
A federal law that allows employees to purchase group insurance through their employers' plans after they leave the company for one of many specified reasons. COBRA coverage is generally offered for up to 18 months, but it can be longer.

Contributory Program
A dental benefits program in which the employee shares in the monthly premium of the program with the program sponsor (usually the employer).

Coordination of Benefits (COB)
A method of integrating benefits payable for the same patient under more than one plan. Benefits from all sources should not exceed 100% of the total charges.

Co-payment
Member's share of the dentist's fee after the benefits plan has paid. This may be a percentage of the dentist's approved fee or a fixed dollar amount.

Cost Sharing
The share of health expenses that a member must pay, including the deductibles, co-payments, co-insurance and charges over the amount reimbursed by the dental benefits plan.

Coverage
Benefits available to a member covered under a dental benefits plan.

Covered Charges
Charges for services rendered or supplies furnished by a dentist that qualify as covered services and are paid for in whole or in part by the dental benefits program. May be subject to deductibles, co-payments, co-insurance, annual or lifetime maximums, as specified by the terms of the contract.

Covered Person
An individual who is eligible for benefits under a dental benefits program.

Covered Services
Services for which payment is provided under the terms of the dental benefits contract.

Credentialing
A process of collecting, verifying and reviewing information concerning a specific dentist. Credentialing is performed before accepting a dentist into a network plan. Credentials are reviewed periodically (e.g. malpractice history, license status, state and Medicare sanctions).

Customary Fee
The fee level determined by the administrator of a dental benefit plan from actual submitted fees for a specific dental procedure to establish the maximum benefit payable under a given plan for that specific procedure. See also Usual, Customary and Reasonable (UCR) Fees.

Deductible
The amount of dental expense for which the beneficiary is responsible before insurance begins to cover the cost. Deductible may be an annual or one-time charge, and may vary in amount from program to program.

Denial of Claim
The refusal by an administrator or insurance company to pay for dental care expenses under the plan.

Dental Benefits Plan
Entitles covered members to specified dental services in return for a fixed, periodic payment made in advance of treatment. Such plans often include the use of deductibles, co-insurance and/or maximums to control the cost of the program to the purchaser. For more about dental benefit plans, click here

Dental Health Maintenance Organization (DHMO)

• Similar to medical HMO concept. Member selects a primary care provider (PCP) from a list of participating providers.
• Members receive all treatment from their primary care provider, unless the PCP authorizes a referral to a specialist.
• Most DHMOs provide preventive care at no charge. Other services may require a co-payment.
• DHMOs pay participating dentists a monthly capitation fee for each patient assigned to his or her practice, regardless of utilization. The dentist assumes the financial risk.

Dependent
Additional members of an individual's household who can be covered by the dental policy. Generally these include a spouse, child(ren) and full-time students.

Direct Billing
A process whereby the dentist bills a patient directly for his/her fee.

Direct Reimbursement
A self-funded program in which the individual is reimbursed based on a percentage of dollars spent for dental care provided, and which allows beneficiaries to seek treatment from the dentist of their choice.

Dual Choice
The member has the option to select from two or more types of dental programs.

Dual Coverage
The member has dental coverage under more than one benefit program. The primary and secondary carriers coordinate the benefits.

Eligibility Date
The date an individual and/or dependents become eligible for benefits under a dental benefits contract. Often referred to as effective date.

Employment Retirement Income Security Act (ERISA)
A federal act, passed in 1974, that established new standards and reporting/disclosure requirements for employer-funded pension and health benefit programs. To date, self-funded health benefit plans operating under ERISA have been held to be exempt from state insurance laws. This exemption is currently under review.

Enrollee
The person enrolled in a dental plan, including both the employee and dependents.

Exclusions
Dental services not covered under a dental benefit program.

Exclusive Provider Organization (EPO)
A dental benefits plan that provides benefits only if care is rendered by dentists with whom the plan contracts. Some exceptions are made for emergency and out-of-area services. The dentists have agreed to a discounted fee.

Expiration Date
The date an individual ceases to be eligible for benefits.

Explanation of Benefits (EOB)
A written statement to a beneficiary, from a third-party payer, after a claim has been reported, indicating the benefit/charges covered or not covered by the dental benefits plan.

Fee for Service
A method of paying dentists a fee for each service.

Fee Schedule
A list of the charges established or agreed to by a dentist for specific dental services.

Flexible Spending Account (FSA)
Employee reimbursement account primarily funded with employee salary deductions. The funds are reimbursed to the employee for health care expenses (medical and/or dental), dependent care, and are considered a nontaxable benefit.

Fraud
The intentional manipulation or alteration of facts submitted by atreating dentist, resulting in a lower or higher payment to the beneficiary and/or the treating dentist than would have been paid if the manipulation had not occurred.

Freedom of Choice
The patient has the right to choose any dentist.

Gatekeeper System
A managed care concept used by DHMOs and EPOs, in which enrollees elect a primary care dentist, usually a general practitioner or pediatric dentist, who is responsible for providing non-specialty care and managing referrals.

HIPAA (Health Insurance Portability & Accountability Act)
A federal law that guarantees health care plan eligibility for people who change jobs, if the new employer offers a group dental plan.

Incentive Program
A dental benefits program that pays an increasing share of the treatment cost, provided that the covered member uses a network dentist.

Indemnity Dental Plan
Also called "fee for service." Patients can go to any dentist. After the member pays the deductible, the patient pays their co-insurance.

Indemnity Plan
A dental plan where a third party provides payment of an amount for specific services, regardless of the actual charges made by the provider. Payment may be made either to enrollees or, by assignment, directly to dentists. Schedule of allowances, table of allowances, or reasonable and customary plans are examples of indemnity plans.

Least Expensive Alternative Treatment (LEAT)
A limitation found in most dental plans that only allow benefits for the least expensive treatment. Also referred to as Least Expensive Professionally Acceptable Alterative Treatment (LEPAAT). Patients choosing more expensive treatment plans may incur significant out-of-pocket costs.

Liability
An obligation for a specified amount or action.

Limitations
Restrictive conditions stated in a dental benefits contract, such as age, length of time covered, and waiting periods, which affect an individual's or group's coverage. The contract may also exclude certain benefits or services, or it may limit the extent or conditions under which certain services are provided. See exclusions in your plan.

Managed Care
Refers to a cost containment system that manages the utilization of health benefits.

Managed Dental Care
In an effort to provide high-quality dental care while controlling costs, the insurance industry has created a system of managed care. DHMO and PPOs are examples of managed dental care whereby dentists join networks and discount their services in order to attract patients.

Maximum Benefit
The maximum dollar amount a program will pay toward the cost of dental care incurred by an individual or family in a specified period, usually a calendar year.

Maximum Plan Benefit
The reimbursement level determined by the administrator of a dental benefit plan for a specific dental procedure. This may vary widely by geographic region or by benefit plans within a region.

Member
An individual enrolled in a dental benefits program. See Beneficiary.

NCQA (National Center for Quality Assurance)
The most highly recognized accreditation organization, by insurance companies and employers, for managed care entities.

Necessary Treatment
A necessary dental procedure or service as determined by a dentist, to either establish or maintain a patient's oral health. Such determinations are based on the professional diagnostic judgment of the dentist and the standards of care that prevail in the professional community.

Network
Dentists who have contractually agreed to follow the plan's procedures.

Noncontributory Program
A method of payment for group coverage in which all of the monthly premium for the program is paid by the employer.

Non-network Dentist
Any dentist who does not have a contractual agreement with a dental benefits organization to render dental care to members of a dental benefits program. Also known as out-of-network dentist.

Open Enrollment
The annual period in which employees can select from a choice of benefits programs.

Out-of-Network
Services rendered by dentists other than those who have contracted to provide care through a network option (PPO, DHMO).

Out-of-Pocket Expenses
Any amount that the member is responsible for paying, such as deductibles, co-payments and costs exceeding the maximum.

Out-of-Pocket Maximums
An annual limit on how much money a member must pay before insurance begins to cover 100% of their dental care expenses.

Overbilling
Nondisclosure of waiver of patient co-payment.

Overcoding
Reporting a more complex and/or higher cost procedure than was actually performed.

Participating Dentist
Any dentist who has a contractual agreement with a network plan to render care to members.

Payer
Either the employer (self-insured or self-funded), the insurance company or the TPA (Third Party Administrator) that finances or reimburses the cost of dental services.

Peer Review
A process established to provide for review by licensed dentists of the care provided by a dentist for a single patient, disputes regarding fees, cases submitted by carriers that are initiated by patients or dentists, and quality of care and appropriateness of treatment.

POS (Point of Service)
Members have the option to select their dentist at the time they are seeking treatment.

PPO (Preferred Provider Organization)

• Members have an incentive to select dentists who have agreed by contract to discount their fees.
• Members have the freedom to choose any dentist, but members who receive treatment outside of the network pay higher co-payments and/or deductibles.

Preauthorization
Statement by a third-party payer indicating that proposed treatment will be covered under the terms of the benefit contract. See also Precertification.

Precertification
Confirmation by a third-party payer of a patient's eligibility for coverage under a dental benefits program. See also Preauthorization, Predetermination.

Predetermination / Pretreatment
An estimate of how much of a proposed treatment plan will be covered under your dental program. It allows the member to figure costs before receiving major treatment. Some plans require a predetermination from your dentist when covered charges are expected to exceed a certain amount, such as $200.

Preexisting Conditions
A condition of a member that existed before enrollment in the dental program.

Premium
The amount paid by an insured in exchange for insurance coverage.

Prepaid Dental Plan
A method of financing the cost of dental care for a defined population, in advance of receipt of services.

Prevailing Fee
Term used by some dental benefit organizations to refer to the fee most commonly charged for a dental service in a given area.

Preventive Services
Refers to dental procedures that prevent the occurrence of dental disease. Diagnostic services detect the presence or absence of disease. Patients can receive long-term benefits by preventing dental disease.

Quality Assessment
The measure of the quality of care provided in a particular setting.

Reasonable and Customary (R&C) fees
Average fees charged for services within your geographic area. Carriers determine the payment they will approve for a visit or procedure using R&C. If a dentist charges a fee higher than this average, the patient may be responsible for the difference. See also Usual, Customary and Reasonable (UCR) Fees

Reasonable Fee
The fee charged by a dentist for a specific dental procedure that has been modified by the nature and severity of the condition being treated and by any medical or dental complications or unusual circumstances, and therefore may differ from the dentist's usual fee or the benefit administrator's customary fee.

Referral Plan
A plan that offers members access to a network of dentists that have agreed to provide services at discounted fees. There is no reimbursement to the patient or to the provider.

Reimbursement
Payment made by a third party to a beneficiary or to a dentist on behalf of the beneficiary, toward repayment of expenses incurred for services.

Schedule of Benefits
A listing of the services for which payment will be made by a third-party payer, without specification of the amount to be paid.

Schedule Plan
A dental benefits plan in which participating dentists agree to accept a list of specific fees as the total fees for dental treatment provided.

Second Opinion
An opinion by a second dentist to confirm or reject another dentist's recommendations.

Self Funding
The method of providing employee benefits, in which the employer does not purchase conventional insurance, but rather elects to pay for the claims directly, generally through the services of a third party administrator.

Self Insurance
Setting aside of funds by an employer to meet anticipated dental care expenses or its dental care claims, and accumulation of a fund to absorb fluctuations in the amount of expenses or claims. The funds set aside or accumulated are used to provide dental benefits directly instead of purchasing coverage from an insurance carrier.

Specialist

• A dentist whose training and expertise are in a specific area of dentistry.
• Endodontists specialize in care for the inner portion of the teeth. Their services include root canals and diseases of the pulp.
• Oral surgeons remove impacted teeth and repair fractures of the jaw and other damage to the bone structure around the mouth.
• Orthodontists correct misaligned teeth and jaws by designing and applying corrective appliance (e.g. braces, retainers).
• Pediatric dentists provide care for infants, children and teenagers
• Periodontists treat diseases of the gums.
• Prosthodontists specialize in replacing missing teeth with implants, bridges and dentures.

Summary Plan Description
See Benefit Plan Summary.

Third Party Administrator (TPA)
Claims payer who assumes responsibility for administering health benefit plans without assuming any financial risk. Some commercial insurance carriers and Blue Cross/Blue Shield plans also have TPA operations to accommodate self-funded employers seeking administrative services only (ASO) contracts.

Unbundling of Procedures
The separating of a dental procedure into component parts with each part having a charge. The cumulative charge of the components is greater than the total charge to patients who are not beneficiaries of a dental benefits plan for the same procedure.

Upcode
Using a procedure code that reflects a higher intensity service than would normally be used for the services delivered.

Usual, Customary, and Reasonable Fees (UCR)
Average fees charged for services within your geographic area. Carriers determine the payment they will approve for a visit or procedure using this average. If a dentist charges a fee that is higher than average, the patient is responsible for the difference.

Usual Fee
The fee which an individual dentist most frequently charges for a specific dental procedure independent of any contractual agreement.

Utilization

• The extent to which the members of a covered group use a program over a stated period of time; specifically measured as a percentage determined by dividing the number of covered individuals who submitted one or more claims by the total number of covered individuals.
• An expression of the number and types of services used by the members of a covered group over a specified period of time.

Utilization Management
A set of techniques used by or on behalf of purchasers of health care benefits to manage the cost of health care by reviewing appropriateness of care based on accepted dental practices.

Utilization Review
A system that examines the distribution of treatment procedures based on claims information. In order to be reasonably reliable, the application of such claims analyses of specific dentists should include data on type of practice, dentist's experience, socioeconomic characteristics and geographic location.

Waiting Period
The period between employment or enrollment in a dental program and the date when a covered person becomes eligible for benefits.