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Dental Insurance Lingo
Balance Billing is the dollar amount charged by the provider that is in excess of the plan's allowed amount for dental treatment.
Basic Services are dental care procedures to restore or repair an individual tooth due to decay, trauma or dental illness. Basic dental services may also include oral surgery, root canal therapy, fillings and tissue/bone treatment.
Benefit Year usually begins the month of the year when the dental plan was purchased.
Claim is a statement sent to the insurance provider from your dentist that lists the dental treatment procedures performed, the date of the treatment and all the associated costs. The claim is a basis for the provider to pay the benefits under the contract.
Cleaning (also known as prophylaxis) is a polishing procedure performed to remove coronal plaque, calculus and stains.
Coordination of Benefits (COB) is a special process of coordinating the benefits offered by different plans if the insured appears to be covered by more than one plan. A patient's coverage is split between the two plans in force according to the guidelines of the National Association of Insurance Commissioners.
Co-insurance is a fixed percentage of charges the insured has to pay in order to cover dental treatment services.
Co-payment is the dollar amount of the fee the insured has to pay the dentist after the insurance company has paid a certain percentage stipulated in the contract.
Covered Charges is the portion of the charges for dental treatment, services or supplies that your insurance provider reimburses under the contract.
Deductible is a fixed dollar amount that a policyholder is to pay each year before the dental plan begins to pay for basic, restorative and orthodontic benefits.
Dental Health Maintenance Organization (DHMO) is a legal entity that accepts the premise to provide the services at a fixed price. The enrollees in these plans are to apply only to the designated specialist working within the network of providers.
Dependent is usually the spouse or the children of the insured. Some dental plans offer extension of coverage and provide the enrollee's dependents with dental care.
Designated Dentist (Designated Provider) is a duly licensed dentist working within the network of providers and thus designated to provide services to the patients joining the network.
Diagnostic Treatment is the procedures performed by the dentist to evaluate the conditions of the teeth and the mouth.
Direct Reimbursement Plan is a dental insurance plan that is usually entirely funded by the employer and allows the insured to see any dentist of his/her choice without any network restrictions.
Explanation of Benefits (EOB) is an itemized statement of incurred dental charges with the specification of the charges paid or denied under the plan.
Fee Schedule is a list of fees a dentist is expected to charge for certain dental care procedures, which determines a specific amount your insurance provider reimburses you for your dental care expenditures. The Fee Schedule is stable and unrelated to a particular dentist's fee.
Filling is the restoration of the lost tooth structure with amalgams, plastic or other suitable materials.
Indemnity Insurance Plans (also Traditional Dental Care Plans or Fee-for-Service Plans) is a variety of plans that provide preventive, basic, major restorative and orthodontic dental coverage. With an Indemnity Insurance Plan you acquire flexibility to choose the professionals you want to apply to.
Major Services are dental care procedures which include inlays, onlays, crowns or veneers, dental surgery, orthodontics, denture work, and other large, expensive dental procedures.
Managed Care Plans are plans that set limits as to the type, level and frequency of treatment as well as control the level of reimbursement for services. These are DHMO plans, PPO plans, POS plans, Closed Panel plans and some others based on the network system of providing benefits.
Medically Necessary is a service or treatment which is appropriate and consistent with a diagnosis and prescribed by the qualified specialists.
Non-participating Dentist is a dentist who has not signed any contract with a network of providers to accept participants of a certain dental plan under stipulated conditions. If you choose a network-based plan, you will have to pay comparatively a lump sum applying to a non-participating dentist.
Orthodontic Treatment is the corrective improvement of teeth through bone by means of an active appliance to correct the malocclusion of the mouth.
Participating Dentist (Provider) is a dentist who signs a contract with the insurance company and agrees to provide dental services and supplies to eligible participants at a fixed price.
Point of Service (POS) Plan is a plan offering the policyholder two types of dental plans combined in one - a traditional fee-for-service plan and a network-based plan.
Preferred Provider Organization (PPO) is a plan under which a policyholder chooses from the network of dentists who provide dental services to the customers participating in the corresponding insurance program and accept discounted fees.
Premium is the dollar amount you are to pay on a regular basis (usually either every month or every year) so that the insurance company could fund your dental plan.
Primary Care Dentist is the dentist or the provider whom the insured selects together with the dental insurance plan.
Provider is a licensed, plan-approved dentist.
Root Canal Therapy is treatment of a tooth with a damaged pulp which usually consists of removing the pulp chamber and root canals and filling the spaces with inert sealing material.
Usual, Customary, and Reasonable Fee (UCR Fee) is a fee associated with each dental procedure which reflects the fees charged by the majority of dentists for the services in question in a given area. The "UCR" fee can help you determine whether your dentist is charging too much.
Waiting Period is a period of time an insurance company will make you wait after your coverage comes into force before the company begins to reimburse your dental care expenses.