Insurance Glossary

With an ASO plan, the plan administrator provides services such as claims processing, customer service, network administration, and marketing services for a fee, but the plan administrator does not assume insurance risk. The plan sponsor assumes this risk and funds a bank account that the plan administrator accesses for claims reimbursement.

The amount upon which a dental insurance plan bases benefit reimbursement is called the allowable amount. The dental service fees that in-network PPO and DHMO dentists agree to accept as payment-in-full are typically considered to be the dental insurance plan's allowable amount. An in-network dentist may not bill you for any additional charges beyond the allowable amount. If the dental insurance plan's allowable amount is less than an out-of-network dentist's dental service fee, the dentist may bill you for any costs above the allowable amount.

The alternative treatment clause is a provision that is often included in a dental coverage contract. This provision states that if more than one dental service may be used to treat a dental condition, the dental insurance plan administrator will base benefits on the least expensive service which meets professionally accepted standards of dental practice. The provision is also referred to as the "Least Expensive Alternative Treatment."

See "Effective date"

This is the total amount of benefit reimbursement a dental insurance plan will provide in a given plan year. Annual maximums typically apply to each enrolled individual and family member. Dental insurance plan reimbursements for orthodontia are generally not applied to the annual maximum, as these services are typically subject to a separate lifetime maximum. Some dental insurance plans may also have separate annual maximums for specific services or treatments such as TMJ disorders or implants. Annual maximums reset at the start of a new plan year (plan anniversary).

Related articles

• Understand How Dental Insurance Plans Work

• Dental Implants
• TMJ Disorders

When a member gives permission for the dental insurance plan administrator to pay your benefits directly to the dentist, it is referred to as an assignment of benefits. Assigning benefits encourages dentists to submit claims for their patients which keeps members out of the insurance transaction process. Once benefit payments are made, dentists will generally bill members for the balance due. Members should take the time to review the Explanation of Benefits (EOB) provided by the dental insurance plan administrator to ensure the billed amount is accurate.

Many Dental Health Maintenance Organization (DHMO) dental insurance plans require members to obtain an authorization from their primary dentist if they or a covered dependent requires care from a specialist such as a periodontist, endodontist, pediatric dentist, or oral surgeon.