Being familiar with insurance terminology helps you better understand your dental benefits.
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.
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.
January 1st through December 31st.
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.
Refers to insurance company.
The person, usually the employee, who represents the family unit covered by the dental benefit program. Other family members are referred to as dependents.
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.
The form used to file for benefits under a dental benefits program.
The process of dentists reviewing specific claims for necessity and payment of benefits.
Person who receives treatment. May be the patient or the certificate holder.
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.
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.
A patient complaint is submitted in writing expressing a disagreement or grievance.
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.
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.
Benefits available to a member covered under a dental benefits plan.
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.
An individual who is eligible for benefits under a dental benefits program.
Services for which payment is provided under the terms of the dental benefits contract.
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).
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.