Insurance Glossary

Dental Insurance Basics

C

COBRA

COBRA (Consolidated Omnibus Budget Reconciliation Act) is a federal law that allows covered dental insurance plan members to maintain group coverage through the dental insurance plan sponsor after they leave the company under certain conditions. The covered member is responsible for the full cost of the dental insurance plan premium plus additional administrative fees. COBRA coverage is generally offered for up to 18 months, but it may be longer under certain circumstances.

Cafeteria plan

With a cafeteria plan, a dental insurance plan sponsor provides a set amount of dollars or credits that members can use to fund premiums for a variety of benefit options. Cafeteria plans often include health, dental, life insurance, and other benefits. These dental insurance plans are also known as Flexible Benefits Plans.

Calendar maximum

See "Annual maximum"

Calendar year

See "Plan year"

Capitation

Dentists that participate in many Dental Health Maintenance Organization (DHMO) dental insurance plans are usually paid a monthly capitation, or per head, fee for each dental insurance plan member that selects them as their primary dentist.

Certificate holder

The certificate holder is the individual who enrolls their family into a dental insurance plan. The certificate holder is referred to as the primary member and other covered family members are referred to as dependents.

Claim review

Dental insurance plan administrators, or a third party operating on their behalf, may employ dentists who review claims for clinical appropriateness. These dentists, known as dental consultants, determine if a procedure on a submitted claim is dentally necessary. They may also recommend that reimbursement be based on a less expensive alternate dental treatment as defined in the alternate treatment clause of the dental insurance plan contract.

Claim submission

Claims may be submitted to the dental insurance plan administrator in writing or electronically. Many dentists submit claims on behalf of their patients.

Claimant

Claimants are covered individuals who receive services or treatment for which a claim is submitted under a dental insurance plan. A claimant is typically the certificate holder or the actual patient if they are a covered dependent.

Co-payment

This refers to a fixed dollar amount that the dental insurance plan member must pay, either for a specific service or an office visit. Co-payments are common in many DHMO dental insurance plans.

Understand How Dental Insurance Plans Work

Coinsurance

This is the percentage that a dental insurance plan administrator (dental insurance plan coinsurance) or member (member coinsurance) will pay for each dental service rendered after any required deductible has been met.

Understand How Dental Insurance Plans Work

Complaint

When a patient has a concern with a dentist's quality of care, or service, safety, or billing concerns and cannot reconcile the issue directly with their dentist, the member may file a complaint with their dental insurance plan administrator to help answer questions and negotiate a suitable resolution. Some complaint resolution support services may only apply when the member has visited an in-network dentist.

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Contracted dentist

See "Network dentist"

Contracted fee

Dentists who participate in a Preferred Provider Organization (PPO) or Dental Health Maintenance Organization (DHMO) contractually agree to provide services at specified fees. The dollar amount for each dental service is referred to as a contracted fee. These fees generally apply only for covered dental services.

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Contributory plan

When a dental insurance plan sponsor contributes a portion of the monthly premium cost for the dental insurance plan, it is called a contributory dental insurance plan.

Coordination of benefits

Coordination of benefits is used by dental insurance plan administrators to ensure that the dentist's total reimbursement will not exceed 100% of the cost of a member's dental care when a member is covered by more than one dental insurance plan.

Cost sharing

Cost sharing is the amount of dental health expenses a dental insurance plan member is responsible for after the dental insurance plan has reimbursed the dentist for services rendered. The member's share, or out-of-pocket expense, typically includes deductibles, co-payments, coinsurance, charges for non-covered services, or expenses exceeding the dental insurance plan's annual maximum.

Coverage

Coverage refers to the level of dental insurance plan reimbursement. Coverage varies by the service provided and is subject to a dental insurance plan maximum, although some DHMO dental insurance plans do not have a maximum.

Covered person

An enrolled member of a dental benefits program is considered a covered person. An enrolled member includes the individual who signed up for coverage, such as an employee, along with any dependents. A covered person may also be referred to as a member or enrollee.

Covered services

Dental insurance plans define the dental services or supplies for which dental insurance plan reimbursement is eligible under the terms of the dental insurance plan contract. Reimbursement levels for covered services vary by the type of service provided.

Credentialing

Before participating in a dental insurance plan administrator's network, dentists must generally undergo a safety and quality review process known as credentialing. The dental insurance plan administrator, or an independent third party, reviews a variety of data sources to ensure that the dentist meets important quality standards. This includes a review of the dentist's license and specialty certifications, liability coverage, malpractice history, billing patterns, treatment quality outcomes, and more. This process is typically repeated every two to three years.

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