Insurance Glossary

Dental Insurance Basics

P

Participating dentist

See "Network dentist"

Plan administrator

A dental insurance plan administrator provides a variety of services on behalf of a program's sponsor. These include claims and customer service, network management, marketing and education resources, and more. The dental insurance plan administrator is often an insurance company or an independent third party.

Plan coinsurance

See "Coinsurance"

Plan documents

See "Plan summary"

Plan maximum

See "Annual maximum"

Plan summary

A dental insurance plan summary is an overview of benefits coverage, limitations, exclusions, dental insurance plan maximums, and other provisions of a dental insurance plan. Dental insurance plan sponsors or administrators are required by law to distribute this document to dental insurance plan members. A dental insurance plan summary may also be referred to as "Plan Documents," or "Summary Plan Description" (SPD).

Plan year

A plan year is the period that starts with the dental insurance plan effective or anniversary date. It is the date the deductibles and dental insurance plan maximums reset. When a plan year begins on January 1st and ends on December 31st, it is said to be a plan calendar year.

Pre-treatment estimate

A pre-treatment estimate is an optional service offered by dental insurance plan administrators that can help members evaluate their anticipated benefit reimbursement and out-of-pocket costs before dental care is rendered. For more expensive services, dentists may submit a pre-treatment estimate to the dental insurance plan administrator on behalf of the member. The pre-treatment estimate will outline the anticipated reimbursement and projected member cost for each dental service the dentist recommends. Pre-treatment estimates may also be referred to as "pre-determination" or "pre-authorization."

Claims and Service Tips

Preferred Provider Organization (PPO)

With a PPO dental insurance plan, members can visit any licensed dentist and receive benefit coverage for services received. However, members also have access to a network of dentists that have agreed to accept reduced fees for services provided. PPO network dentists are subject to a screening process called credentialing.

Preferred dentist

See "Network dentist"

Premium

Premium is the cost of dental coverage. Most employer-sponsored dental insurance plans are available to members on a pre-tax basis, which offers additional savings. Dental insurance plan premiums may be shared between the employer and the member (contributory dental insurance plan) or fully paid by the employer (non-contributory dental insurance plan).

Preventive and diagnostic care

These services are commonly referred to as Class/Unit I or Type A services for reimbursement purposes, and are designed to help prevent dental disease or identify problems before they worsen. Examples include routine exams, X-ray images, cleanings, fluoride treatments, sealants, and space maintainers. Dental insurance plans vary in how they categorize services, so it is important to review your open enrollment materials and dental insurance plan summary to understand the coverage levels of services you expect to receive.