Being familiar with insurance terminology helps you better understand your dental benefits.
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.
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.
A process whereby the dentist bills a patient directly for his/her fee.
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.
The member has the option to select from two or more types of dental programs.
The member has dental coverage under more than one benefit program. The primary and secondary carriers coordinate the benefits.