A

Audit: An inspection of documents or transactions to ensure their accuracy and correctness. A review of post-treatment records or a clinical evaluation to ascertain the accuracy of information reported on claims.

Attending dentist’s statement: A discontinued and outdated term for the American Dental Association’s (ADA) Dental Claim Form. Refer to “Claim form” to get more information about the term.

Assignment of benefits: A procedure in which a patient/beneficiary authorizes the program’s administration to pay the treating dentist directly for a covered operation.

Appeal: A formal appeal to an insurer to conduct an audit of unpaid or refused claims for supplies or services rendered. A healthcare practitioner or a patient may file an appeal in order to obtain compensation from a third-party payer, such as a private insurance company.

Any willing provider: Legislation requiring managed care organizations (MCOs), such as preferred provider organizations (PPOs) and health maintenance organizations (HMOs), to contract with any provider willing to comply with the contract’s requirements.

ANSI/ADA/ISO: Abbreviations for organizations that create or implement international and national standards. The ANSI (American National Standards Institute) is a non-profit organization formed in the United States for the goal of coordinating and accrediting product standard development operations.

The ADA (American Dental Association) is an ANSI-accredited national standards development body. The ISO (International Organization for Standardization) is a federation of national standards agencies operating on a global scale. ISO publishes the results of its technical effort as International Standards. ANSI coordinates efforts in the United States toward the creation of ISO standards.

Alternate benefit: A clause in a dental plan contract that allows the third-party payer to calculate the benefit based on a less expensive procedure than the one proposed or supplied.

Allowable charge: The maximum monetary amount on which each dental procedure’s benefit payment is based, as determined by the third-party payer.

Administrator: A person who oversees or directs a dental benefit program on behalf of its sponsor. For more information, see third-party administrator and dental benefit organization.

Administrative services only (ASO): A fee-based structure in which a third party processes claims and manages paperwork for a self-funded organization. Except for risk assumption, this typically covers all insurance company services (benefit description, underwriting, actuarial services, and so on).

Administrative costs: Overhead charges incurred in the running of a dental benefit program, excluding dental service costs.

B

Bundling of procedures: Third-party payers’ systematic mixing of various dental operation codes, leading to a decreased benefit for the beneficiary/patient.

Birthday rule: When both parents of a dependent child have dental insurance, the primary program (the one that pays first) is the one that covers the parent whose month and day of birth correspond with the first month and day of the calendar year, according to this regulation. Although the birthday rule is the most commonly used way for distinguishing between primary and secondary coverage, it can be overruled by a court decision, such as a divorce agreement.

Benefit plan summary: The explanation or overview of employee benefits that is required to be delivered to employees under ERISA.

Benefit booklet: A pamphlet or booklet supplied to subscribers that contains an overview of the dental benefit program’s benefits and related provisions. Additionally referred to as a Summary Plan Description.

Benefit: Amount payable by a third party toward the cost of varied covered dental services or the cost of the covered dental treatment or procedure.

Beneficiary: A individual who qualifies for benefits under a dental benefit contract. For more information, see member, covered person, and insured.

Balance billing: Charging a patient for the difference between the amount covered by the patient’s dental benefit plan and the dentist’s actual charge.

Bad faith insurance practices: Failure to deal honestly and in good faith with a beneficiary of a dental benefit plan; or a behavior that affects the beneficiary’s right to obtain the appropriate benefit of a dental benefit plan or to get it in a timely way.

Potential bad faith insurance practices include: arbitrarily and purposefully delaying and/or withholding payment of a claim, evaluating claims based on standards that are significantly different from community standards, and failing to adequately investigate a claim for care. See prompt payment laws.

C

Covered services: Dental services that are compensated in accordance with the conditions of a dental benefit contract.

Covered person: An individual who is entitled to receive benefits under a dental benefit plan.

Covered charges: Dentist fees that are paid in part or in whole under the terms of the dental benefit plan, subject to all of the insurance policy’s or agreement’s limitations and terms. Any exclusions, contractual agreements, and limitations applied to reimbursement amounts.

Coverage: Benefits available to a person insured by a dental insurance program.

Cost sharing: The portion of a beneficiary’s health-care expenses that must be paid, including charges, coinsurance, copayments, and deductibles in excess of the amount covered by the dental insurance plan.

Cost containment: Features of a dental benefit program or of the program’s management that are intended to decrease or eliminate certain payments to the plan.

Copayment: After the insurance plan has paid, the beneficiary’s part of the dentist’s fee.

Coordination of benefits (COB): A way of combining benefits payable for the same patient under multiple plans. Benefits from all sources combined should not be more than 100 percent of total charges, unless otherwise specified.

Contributory program: A dental insurance program in which the enrollee co-pays the monthly premium with the plan’s sponsor (usually the employer). Payroll deduction is the most common method.

Contract term: Typically, a contract is written for a 12-month term during which a group’s deductibles, maximums, and other provisions apply. This may or may not correspond to a calendar year. Also referred to as the benefit year.

Contract: A legally enforceable contract between two or more individuals that vests the parties with rights and obligations. Contracts of the following types are frequently used: 1) contracts between an individual dentist and dental benefit organization for the purpose of providing dental care to members of a benefit plan.

These contracts specify the dentist’s obligations to both the dental benefit plan’s beneficiaries and the dental benefit organization, as well as how the dentist will be compensated; and 2) contracts between a group plan sponsor and dental benefit organization. The advantages of the group plan, as well as the costs at which those benefits will be charged, are often detailed in these contracts.

Consolidated Omnibus Budget Reconciliation Act (COBRA): Legislation governing required benefits under all sorts of employee benefit schemes. The most essential components in this context are the requirements for ongoing coverage for employees and/or their dependents for an additional 18 months after they would have lost coverage otherwise (30 months for dependents in the event of the employee’s death).

Coinsurance: A feature of a dental insurance program in which the beneficiary pays a percentage of the cost of covered services. The portion of a covered dental expense that a recipient is responsible for (after the deductible is paid). A typical coinsurance agreement is one in which the third party pays 80% of the allowable benefit for the covered dental service and the beneficiary pays the remaining 20%. Percentages vary and may apply to plans with a table of allowances, plans with a maximum permissible benefit, and programs with direct reimbursement.

Closed panel: A dental benefit plan that requires qualified patients to seek dental care from a specified dentist who has contractually agreed to the plan’s benefits, rules, and payments. Typically, these types of schemes enable only a restricted number of dentists in a given area to participate.

Claims reporting fraud: Intentional distortion of material facts about treatment performed and/or expenditures incurred in order to obtain a bigger payment.

Claims payment fraud: Manipulation or alteration of facts or procedure codes reported by a treating dentist, resulting in a lower payment to the beneficiary and/or the treating dentist than would have been paid if the manipulation had not occurred.

Claimant: A person or authorized provider who files a benefit claim.

Claim form: A paper or computer document that is used to record dental procedures to a third-party payer in order to file for benefits under a dental benefit program. The American Dental Association created the paper claim form.

Claim: A payment request under a dental benefit plan; a statement outlining services rendered, dates of services, and cost itemization. The completed request serves as the foundation for benefit disbursement.

Centers for Medicare and Medicaid Services (CMS): The federal agency in charge of the Clinical Laboratory Improvement Amendments (CLIA), HIPAA, State Children’s Health Insurance Program (SCHIP), Medicaid, Medicare, and programs. CMS is a division of the United States Department of Health and Human Services.

Capitation: A capitation program is one in which a dentist or dentists enter into a contract with the program’s sponsor or administrator to offer all or most of the dental treatments covered by the program to subscribers in exchange for a per-capita payment.

Cafeteria plan: Employee benefit plan in which employees select their medical insurance and other nontaxable fringe benefits from an employer-provided list. If members in cafeteria plans elect less expensive perks, they may get additional taxable cash compensation.

D

Dual choice program: A benefit package that enables an eligible individual to enlist in either an traditional or alternative dental coverage program.

DRGs (diagnosis related groups): A classification system for hospital patients based on their diagnosis, consisting of several categories. A case is assigned a DRG depending on the following: 1) the patient’s primary diagnosis; 2) the treatment methods done; 3) the patient’s age; 4) the patient’s gender; and 5) the patient’s discharge status.

Downcoding: A mechanism used by third-party payers to adjudicate claims in which a procedure code is substituted for the one reported on the claim, resulting in a reimbursement amount less than what would be authorized for the submitted code.

Direct reimbursement: A self-funded scheme in which the individual gets compensated based on a proportion of the dollar amount spent on dental care and which allows beneficiaries to see any dentist they wish.

Dependents: Generally, the insured individual’s spouse and children, as determined by the conditions of the dental benefit contract.

Dentistry: Assessment, prognosis, mitigation, and treatment (surgical, nonsurgical, or related procedures) of conditions, disorders, and diseases of the maxillofacial area, oral cavity, and/or associated and adjacent structures, and their impact on the human body; given by a dentist within the scope of his/her experience, education, and training, in compliance with applicable law and professional ethics.

Dental prepayment: A technique of financing the cost of dental services before they are rendered.

Dental home: According to the ADA policy, the ongoing relationship between the dentist who is the Primary Dental Care Provider and the patient, which includes comprehensive oral health care, should begin no later than age one..

Dental enrollment credentialing: A systematic process that establishes the norms and requirements for third-party program participation. The method verifies professional credentials in order to authorize licensed dentists to give services to members of the program.

Dental benefit program: The sponsor’s specific dental benefit package that is being provided to subscribers.

Dental benefit organization: Any organization that provides dental benefits. Additionally referred to as a dental plan organization.

Deductible: The amount of dental expense that the beneficiary is accountable for before a third party assumes responsibility for benefits payment. The deductible may be one-time or annual in nature, and the amount may vary by program. See family deductible.

E

Extension of benefits: Extension of eligibility for covered services, typically to ensure that treatment begun prior to the expiration date is completed. Generally, duration is given in units of days.

Extended care facility: A facility, such as a nursing home, that is licensed to offer nursing care 24 hours a day in compliance with applicable state and municipal rules. Care may be offered on a variety of levels: custodial, skilled, intermediate, or any combination thereof.

Explanation of benefits (EOB): After a claim has been evaluated, a third-party payer will send a beneficiary a written statement outlining the charges covered or not covered by the dental insurance plan.

Expiration date: The date on which a dental benefit contract ends; the date on which an individual loses eligibility for benefits.

Exclusive Provider Organization (EPO): A type of preferred provider organization in which employees are required to utilize dentists from a specific network in order to obtain coverage; care received from a non-network provider is not covered except in an emergency circumstance.

Exclusions: Dental services that are not covered by a dental benefit plan.

Evidence-Based Dentistry: An approach to oral health care that incorporates clinically relevant scientific data on the patient’s oral and medical state and history with the dentist’s clinical skills and the patient’s treatment needs and preferences.

Established patient: A patient who has received professional services from a dentist or another dentist in the same specialty who is a member of the same group practice within the preceding three years, subject to applicable state legislation.

Entity: Something that exists in the form of a separate and distinct unit. Under the law, individuals and corporations are considered to be comparable entities.

Enrollee: A person who is covered by a benefit plan. See beneficiary.

Endodontist: A dental expert whose practise is limited to the treatment of pulp disease and injury, as well as concomitant periradicular disorders.

Endodontics: Endodontics is the discipline of dentistry that studies the pathology, morphology, and physiology of periradicular tissues and the human dental pulp. Its theory and practice incorporate fundamental and clinical sciences, such as the biology of normal pulp, the origin, diagnosis, prevention, and treatment of pulp illnesses and injuries, as well as associated periradicular disorders.

Employment Retirement Income Security Act (ERISA): A 1974 federal law that created new criteria and reporting/disclosure requirements for employer-sponsored pension and welfare benefit programs. Until now, courts have held that self-funded health benefit plans operating under ERISA are exempt from the majority of state insurance laws, though they have also held that states may regulate the medical care provided under such plans, for example, by requiring mandatory review of adverse HMO determinations.

Eligible person: See beneficiary.

Eligibility date: Individuals and/or dependents become eligible for benefits under a dental benefit contract on the date they become eligible. Frequently abbreviated as effective date.

Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT): A federal program that provides comprehensive health care to children through routine screenings, diagnostic services, and treatment. Extended care facility (ECF): See extended care facility.

F

Full fee: See fee.

Freedom of choice: The belief that a patient has the unfettered right to choose any licensed dentist to provide oral health care.

Flexible spending account: Employee reimbursement account financed mostly from salary reductions designated by employees. Funds are reimbursed to employees for dependent care, health care (dental and/or medical), and/or legal expenses and are not taxable.

Flexible benefits: A benefit program in which an employee may choose from a variety of benefit options, such as pension benefits, child care, dental coverage, and disability and health insurance. See cafeteria plans; flexible spending account.

Fee schedule: A list of the fees charged by a dentist for specific dental services that have been defined or agreed to by the dentist.

Fee-for-service: A repayment mechanism in which the dentist establishes and anticipates receiving the full fee for the specific service(s) done.

Usual, Customary and Reasonable Fees: These are three distinct acronyms that are frequently misapplied interchangeably, synonymously, or as a single phrase abbreviated as “UCR” when discussing dental insurance plans and their associated payments. The ADA advises against using this word.

Maximum plan benefit: The reimbursement level for a certain dental procedure as decided by the administrator of a dental benefit plan. This varies significantly by geographic region and within-region benefit arrangements.

Full fee: The fee determined by the dentist for a service that represents the costs of conducting the procedure and the dentist’s expert opinion. A contractual arrangement has no bearing on the total amount charged by a dentist. It is always necessary to submit the whole fee for each service to a third-party payer.

Fee: The monetary value assigned to a dental procedure performed on a patient by a dentist. The following definitions apply to numerous words that involve the term or concept of a fee.

Family deductible: A deductible that is met by the sum of all covered family members’ expenses. For instance, a program with a $25 deductible may cap enrollment at three deductibles, or $75 per family, regardless of the number of family members. See deductible.

G

Gate keeper system: Some alternative benefit plans use a managed care approach in which subscribers choose a primary care dentist, usually a pediatric dentist or general practitioner, who is responsible for handling referrals and non-specialty care for ancillary and specialty care as needed.

H

Hold harmless clause: A contractual agreement in which one party agrees to take responsibility for the other’s obligations. In the following instances, hold harmless clauses are commonly used:

1) Dental benefit organization contracts with individual dentists usually contain a commitment by the dentist to reimburse the dental benefit organization for any liability incurred as a result of dental care provided to dental benefit plan beneficiaries. This could include a promise to cover the dental benefit organization’s legal fees and other costs.

2) A promise by the dental benefit organization to assume responsibility for disputes between a group plan beneficiary and an individual dentist when the dentist’s charge exceeds the amount the organization pays for the service on behalf of the beneficiary may be included in contracts between dental benefit organizations and a group plan sponsor.

The dental benefit organization will take over the defense of the claim and will pay any judgments and court costs if the dentist pursues action against the patient to recover the difference between the amount billed by the dentist and the amount paid by the organization.

Health Maintenance Organization (HMO): A legal entity that assumes responsibility and financial risk for providing specified services to a designated population at a predetermined price for a specified length of time. A structured system of health care delivery in which subscribers receive full care from designated providers. Generally, enrollees are charged a monthly fee for health care services and may be forced to remain in the program for a defined period of time.

Health Insurance Portability and Accountability Act (HIPAA) of 1996: A federal statute that includes Administrative Simplification Provisions requiring all health plans, including those governed by ERISA, as well as health care clearinghouses and any dentist who communicates health information electronically, to adopt a uniform format. Additionally, the HIPAA-compliant electronic dental claim requires the use of the American Dental Association’s Code on Dental Procedures and Nomenclature code set. This criterion does not apply to paper transactions.

Health Care Financing Administration (HCFA): See Centers for Medicare and Medicaid Services.

I

Insured: Individuals covered by a insurance program. See beneficiary.

Insurer: In an insurance policy, the party that guarantees payment of a benefit if a defined loss happens. Typically, this is an insurance business.

Individual Practice Association (IPA): A legal entity created and administered by participating dentists with the primary objective of collectively contracting for the provision of dental services to registered populations.

Indemnity plan: A non-network dental plan that reimburses the member or dentist at a percentage of the charges for services performed, typically after the deductible is met. Typically, indemnity policies do not restrict a member’s choice of dentist. Indemnity policies are often known as fee-for-service policies.

Indemnification schedule: See table of allowances.

Indigent: As defined by the federal Office of Management and Budget (OMB), those individuals whose income falls below the poverty line

Incentive program: A dental benefit program that covers a rising share of the treatment cost as long as the insured individual uses the program’s benefits during each incentive period (typically a year) and obtains the prescribed treatment.

For example, if a subscriber visits the dentist as specified in the program during the first year of coverage, a 70% – 30% copayment program in the first year of coverage may be converted to an 80% – 20% program in the second year.

If a covered individual fails to visit the dentist in a given year, the program’s copayment level is typically reduced by a corresponding percentage (but never below the initial copayment level).

Inappropriate fee discounting practices: Intentionally engaging in actions that would compel a dentist who does not have a participating provider agreement to accept reduced fees or be bound by the terms and circumstances of the participating provider contract.

The following are a few examples of fee discounting techniques that aren’t appropriate: sending reimbursement cheques that, upon signature, require the dentist to accept the amount as full payment; using claim forms that, upon signature, require the dentist to accept the terms of the plan’s contract; issuing insurance cards that state that the submission of a claim by a dentist constitutes acceptance of all terms and conditions set forth in the participating provider contract.

J

There are no administrative terms beginning with “J.”

K

There are no administrative terms beginning with “K.”

L

Limitations: Restriction clauses in a dental benefit contract, such as waiting periods, age, and duration of coverage, that limit a group’s or individual’s coverage. Additionally, the contract may exclude some services or benefits or restrict the scope or terms under which particular services are delivered. See exclusions.

Liability: A contractual obligation to pay another party money, commodities, or services.

Least expensive alternative treatment (LEAT): Contractual wording that requires a plan to pay for the least expensive treatment option when there are multiple treatment options for a condition.

M

Most Favored Nation Clauses: Contractual language requiring a dentist to charge dental plan beneficiaries the same reduced rate as the practitioner charged another patient.

Member: A person who is enrolled in a dental benefit plan. See beneficiary.

Medicare: A federal insurance program established in 1965 under Title XVIII of the Social Security Act that covers some inpatient hospital services and physician services for all persons 65 years of age and disabled adults who qualify. The Centers for Medicare and Medicaid Services (CMS), formerly known as the Health Care Financing Administration, administers the program (HCFA).

Medically necessary care: The follow-up care, diagnosis, and treatment (including gadgets, supplies, and appliances) prescribed and determined by qualified, appropriate health care providers in treating any injury, disease, illness, or birth developmental abnormalities. Medical care is required for the following reasons: controlling or removing disease, infection, and pain; and restoring face structure or function required for chewing, speech, or swallowing.

Medicaid: Title XIX of the Social Security Act of 1965 established a federal aid program that pays for medical treatment for certain low-income people and families. The program is jointly funded and supervised by the state and federal governments.

Maximum plan benefit: The level of payment set by the administrator of a dental benefit plan for a given dental operation. This might vary greatly depending on the geographic region or the benefit programs within a region.

Managed care: Any contractual arrangement in which a third party controls payment, reimbursement, and/or utilization. The term “managed care” refers to a cost-cutting system that directs health-care utilization by: a.) regulating the type, level, and frequency of treatment; b.) limiting access to care; and c.) controlling the level of payment for treatments.

N

Nonparticipating dentist: Any dentist who does not have a formal agreement with a dental benefit organization to provide dental care to dental benefit program participants.

Nonduplication of benefits: When a patient is covered by two benefit plans, the secondary carrier may calculate its portion of the payment in one of two methods. The secondary carrier assesses how much it would have paid if it had been the primary plan and subtracts how much the other plan paid. For example, if the primary carrier paid 80% and the secondary carrier generally covers 80%, the secondary carrier would make no additional payment. However, if the principal carrier paid 50%, the secondary carrier might pay up to 30%.

Non-covered charges: See covered charges.

Noncontributory program: A group coverage payment option in which the sponsor pays the entire monthly premium for the program.

Necessary treatment: A dental procedure or service that is required by a dentist to establish or maintain a patient’s oral health. Such conclusions are based on the dentist’s professional diagnostic judgement and the professional community’s standards of care.

National Provider Identifier (NPI): The federal government assigns this identity to all providers who are designated HIPAA covered entities. Dentists who are not covered entities may choose to obtain an NPI at their discretion, or they may be listed if mandated by a participating provider agreement with a third-party payer or applicable state law/regulation.

An NPI is a number that is unique to a single dentist or dental institution and has no inherent meaning. Dentists and dental practices can use one of two types of NPIs:

Type 1 Individual Provider–A single human being who is a health care practitioner. ALL dentists, regardless of whether they are protected by HIPAA, are certified to apply for Type 1 NPIs.

Type 2 Organization Provider–A health-care provider that is a business, such as a corporation or a group practice. Individual dentists who are incorporated may be classified as Type 2 providers in addition to Type 1 providers. Enumeration as a Type 2 provider is open to all incorporated dental clinics including group practices.

On paper, there is no way to tell a Type 1 from a Type 2 without any related data; their formats are identical.

National Association of Insurance Commissioners (NAIC): The National Group of Insurance Commissioners is a professional or trade association for state insurance departments (http://www.naic.org).

O

Overcoding: Reporting a more complicated and/or more expensive operation than was performed.

Overbilling: When an insurance company is billed a higher price to help fund the patient’s co-payment or to raise a fee purely because the customer is insured by a dental benefits plan, the fee is misrepresented as higher than the actual charges.

OSHA: The Occupational Safety and Health Administration is known by this abbreviation. A U.S. government agency that sets and enforces workplace safety rules for the nation’s workers.

Orthodontics and dentofacial orthopedics: Malocclusions, as well as neuromuscular and skeletal anomalies of the growing or mature orofacial structures, are addressed by orthodontics and dentofacial orthopedics, which is a dental specialty.

Orthodontist: A dental expert whose practice is limited to the treatment and interception of malocclusion and other skeletal and neuromuscular of the teeth and their surrounding structures.

Oral health literacy: The degree to which individuals have the capacity to access, analyze and understand fundamental health information and services needed to make healthy oral health decisions.

Oral diagnosis: The determination of an individual patient’s oral health condition by a dentist by the review of data obtained through history gathering, direct examination, patient conference, and such clinical aids and tests as the dentist deems necessary.

Oral and maxillofacial surgery: Oral and maxillofacial surgery is a dental specialty that covers the diagnostic, surgical, and adjunctive treatment of diseases, injuries, and anomalies involving both the functional and esthetic elements of the oral and maxillofacial region’s hard and soft tissues.

Oral and maxillofacial surgeon: A dental specialist whose practice is limited to the diagnostic, surgery and adjuvant treatment of diseases, injuries, deformities, abnormalities and esthetic features of the oral and maxillofacial areas.

Oral and maxillofacial radiology: Oral and maxillofacial radiology is a dental specialty and radiology discipline concerned with the creation and interpretation of pictures and data generated by all modalities of radiant energy used to diagnose and treat diseases, disorders, and conditions of the oral and maxillofacial region.

Oral and maxillofacial radiologist: A dentist who specializes in the creation and interpretation of images and data generated by all modalities of radiant radiation utilized in the diagnosis and management of diseases, disorders, and conditions of the oral and maxillofacial region.

Oral and maxillofacial pathology: Oral pathology is the branch of dentistry and subject of pathology that deals with the nature, detection, and therapy of disorders affecting the oral and maxillofacial areas. It is a science that explores the causes, methods, and effects of various disorders. The practice of oral pathology comprises investigation and diagnosis of disorders utilizing biochemical, microscopic, clinical, radiographic or other exams.

Oral and maxillofacial pathologist: A dentist who specializes in the recognition, diagnosis, investigation, and management of illnesses of the oral cavity, jaws, and associated structures.

Open panel: This sort of dental benefits plan allows eligible consumers to see any dentist and any dentist to participate. Any dentist may accept or decline to treat plan participants. Open panel plans are often known as freedom of choice plans.

Open enrollment: Employees can choose from a variety of benefit plans during the annual period.

P

Purchaser: Organization or body, generally union or employer, that contracts with the dental benefit organization to provide dental coverage to an enrolled population.

Public health dentistry: The science and art of preventing and managing dental illnesses, as well as promoting dental health via coordinated community activities, is known as dental public health. It is that type of dentistry business that serves the community rather than the individual as a patient. It is involved with public dental health education, applied dental research, and the management of group dental care programs, as well as the community-wide prevention and control of dental diseases.

Public health dentist: A dentist whose practice is confined to the science and art of preventing and managing dental diseases, as well as promoting oral health via community-wide activities.

Prosthodontist: A dental professional whose practice is confined to the repair of natural teeth and/or the artificial replacement of missing teeth.

Prosthodontics: Prosthodontics is a dental specialty concerned with the maintenance, rehabilitation, treatment planning, and diagnosis of oral health, appearance, function, and comfort in patients suffering from clinical conditions caused by oral and maxillofacial tissues or missing or deficient teeth using biocompatible substitutes.

Proof of loss: Verification of services provided or charges spent by the submission of claim forms, radiographs, study models, and/or other diagnostic material Documentary proof required by a payer to demonstrate the existence of a legitimate claim. It is generally in the form of a claim form filled out by the patient’s treating dentist.

Prompt payment laws: Regulations governing fair claims practice are often known as fair claims practice regulations. Fast payment rules, which are enacted state by state, set criteria for the prompt, fair, and equitable settlement of insurance claims by requiring that a certain amount of interest be paid on “clean claims” that are paid beyond the stipulated deadline.

A “clean claim” is defined as a claim for payment of covered health care expenses submitted to a payer on the carrier’s standard claim form using the most recent published procedural codes, with all required fields filled out with information sufficient to adjudicate the claim in accordance with the payer’s published filing requirements. These statutes must be examined on a case-by-case basis to decide if the state department of insurance must initiate a lawsuit.

Prior authorization: See predetermination.

Primary payer: The third party payer deemed to have first obligation in a benefit determination.

Preventive dentistry: Aspects of dentistry dealing with supporting excellent oral health and function by avoiding or minimizing the beginning and/or development of oral disorders or abnormalities and the occurrence of oro-facial traumas.

Pretreatment estimate: See predetermination.

Prepaid group practice: See closed panel.

Premium: The fee charged by a dental benefit organization for a set level of benefits for a set period of time.

Prefiling of fees: The submission of a participating dentist’s complete fees in order to establish, in advance, that dentist’s full fees and the fees in a geographic area in order to determine benefits under a dental benefit program.

Preferred Provider Organization (PPO): A legal agreement between a purchaser of a dental benefit program and a designated group of dentists for the supply of dental care to a specific patient demographic, as an addition to a regular plan, employing discounted fees for cost savings.

Pre-existing condition: An enrollee’s oral health condition that existed prior to enrolment in a dentistry program.

Predetermination: Before starting treatment, a dentist presents a treatment plan to the payer. The payer examines the treatment plan and informs the dentist and the patient of one or more of the following: the patient’s eligibility, plan maximums, deductibles, co-payments, amounts due, and covered services.

Precertification: Confirmation of a patient’s eligibility for coverage under a dental benefit scheme by a third-party payer. See preauthorization, predetermination.

Preauthorization: A statement from a third-party payer indicating that the planned therapy is covered by the conditions of the benefit contract. See also precertification, predetermination.

Post-treatment review: See audit.

Point of service: A health plan allowing the member to select to get a service from a participating or non-participating provider, usually with various benefits levels connected with the use of participating providers.

Periodontist: A dental specialist whose practice is restricted to the treatment of illnesses of the teeth’s supporting and surrounding tissues.

Periodontics: Periodontics is the dental specialty concerned with the prevention, diagnosis, and treatment of illnesses of the supporting and surrounding tissues of teeth or their substitutes, as well as the preservation of the health, function, and esthetics of these structures and tissues.

Percentile: The number in a frequency distribution below which a particular percentage of fees will fall. For example, the 90th percentile is the figure that separates the distribution of fees into the lower 90 percent and the higher 10 percent, or that fee level at which 90 percent of dentists charge that amount or less, and 10 percent more.

Peer Review Organization (PRO): An agency created by an amendment to the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) to review medical services delivered largely in a hospital setting and/or in conjunction with treatment given under the Medicare and Medicaid programs. In addition to reviewing and monitoring, these entities might impose sanctions, penalties, or other remedial actions for noncompliance with organizational norms.

Peer review: A professional equal’s (peers) judgment of the quality and conduct of an individual’s work in order to address problems or disputes about the quality or conduct of the job. When applied to dentistry, peer review is a process that organized dentistry has consistently structured and implemented in which a dentist’s professional equals (peers) resolve disputes or questions (regarding the fairness of the fee the dentist charged and/or appropriateness or quality of care received from the dentist) by retrospectively analyzing the appropriateness or quality of care in relation to the criteria of professional criteria or norms.

Pedodontist: See pediatric dentist.

Pediatric dentistry: Pediatric dentistry is an age-defined specialization that provides primary and thorough preventative and curative oral health care to infants, children, and adolescents, including those with unique health care needs.

Pediatric dentist: A pedodontist or pediatric dentist is a dental expert whose practice is restricted to the treatment of children from birth to puberty, offering primary and complete preventative and therapeutic oral health care.

Payer: A self-insured employer, insurance firm, governmental agency or other body liable for payment of health care claims of covered persons.

Patient: A person who has formed a professional partnership with a dentist in order to provide dental health care. For purposes of information and consent transmission, this phrase encompasses the patient’s parent, carer, guardian, or other individual as appropriate under state law and the circumstances of the case.

Participating practice (in-network practice): Any dental office or organization that has a contract with an insurer to provide services under an insurance contract.

Participating dentist (in-network dentist): Any dentist who has a contract with a dental benefit group to provide services to eligible patients.

Q

Quadrant: Beginning at the midline of the arch and extending distally to the last tooth, this is one of the four equal portions into which the dental arches can be split.

R

Risk pool: In an alternate benefit plan, a portion of provider fees or capitation payments is withheld as a financial reserve to cover unplanned consumption of services.

Retrospective review: After the services have been performed, a case-by-case or aggregate post-treatment assessment of the services is undertaken.

Retail store dentistry: Dental services provided in a retail, department, or drug store environment. Typically, a separate administrative entity leases space from the store, which is then subleased to a dentist or dental group that provides the actual dental treatments. The dental office is usually open at the same hours as the store, and appointments are rarely required. Not a dental benefit plan model, but rather a type of practice.

Relative Value System: Professional services are coded and given unit values to show their relative complexity as assessed by time, skill, and overhead expenses. To determine provider reimbursement, third-party payers usually give a dollar value per unit.

Reinsurance: Third-party payers can buy insurance to spread the risk of losses (claims paid) over a certain cash amount.

Reimbursement: Payment given by a third party to a beneficiary or a dentist on the beneficiary’s behalf to reimburse expenditures incurred for a dental benefit plan-covered service.

S

Stop-loss: A broad word for the type of coverage that provides an employer with insurance protection (reinsurance) for a self-funded plan.

Summary plan description: See benefit plan summary.

Statistically-based utilization review: Based on claims data, a system that examines the distribution of treatment processes. For such claims evaluations of specific dentists to be reasonably reliable, data on geographic area, socioeconomic characteristics, dentist experience, and type of practice should be included.

Service corporations: Delta Dental Plans, Blue Cross and Blue Shield Plans are examples of dental benefit organizations created under not-for-profit state statutes for the aim of providing health care coverage.

Self-insurance: Individuals or organizations set aside funds to cover forecasted dental care bills or claims, as well as accumulate a reserve to absorb variations in the amount of claims or expenses. Instead of obtaining coverage from an insurance carrier, the cash accumulated or set aside are used to give dental benefits directly.

Self-funded plan: A benefit plan in which the plan sponsor is solely responsible for the plan’s utilization. If the sponsor uses indemnified stop-loss insurance to guard against the risk of unforeseen increased utilization, some plans may be largely self-funded. Third-party administrators can handle claims processing and other administrative tasks without taking on any of the plan’s risks.

Second-opinion program: An opinion from a practitioner other than the one who made the original suggestion about the appropriateness of a proposed therapy; some benefit plans demand such opinions for certain treatments.

Schedule of benefits: A list of dental services and the maximum benefit amounts that an insurance company will pay for each one. The level of specificity will differ depending on the benefit package.

Schedule of allowances: See table of allowances.

T

Title XIX: Part of the Social Security Act that authorizes the federal government to make subsidies to states for medical assistance programs, sometimes known as Medicaid.

Third-party payer: An organization participating in the financing of personal health services that is not the patient (first party) or the health care provider (second party).

Third-Party Administrator (TPA): Without taking any financial risk, a claims payer bears responsibility for running health benefit plans. TPA operations are also available from some commercial insurance carriers and Blue Shield & Blue Cross plans to help self-funded employers seeking administrative services only (ASO) contracts.

Third-party: The party who collects premiums, assumes financial risk, pays claims, and/or performs other administrative services under a dental benefit contract. Administrative agent, carrier, insurer, or underwriter are other terms for the same thing.

Termination date: See expiration date.

Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA): Health maintenance organizations, as well as the Medicare and Medicaid programs, are affected by legislation (Public Law 97-248). Establishes additional rules for the foundation and operation of peer review bodies, as well as restrictions for the development of HMO risk contracting with the Medicare program.

Table of allowances: A list of covered services with a monetary figure that indicates the plan’s total payment obligation for that service, but does not necessarily represent the dentist’s full cost for that service.

U

Utilization review, statistically based: A system that assesses the distribution of treatment procedures based on claims data; to be reasonably trustworthy, such claims analyses of specific dentists should contain data on type of practice, dentist experience, socioeconomic characteristics, and geographic area.

Utilization management: A set of techniques used by or on behalf of purchasers of health care benefits to influence patient care decision-making through case-by-case assessments of the appropriateness of care based on accepted dental practices in order to manage the cost of health care prior to its provision by influencing patient care decision-making through case-by-case assessments of the appropriateness of care.

Utilization: The percentage of covered individuals who submitted one or more claims divided by the total number of covered individuals; typically calculated as a percentage determined by dividing the number of covered individuals who submitted one or more claims by the total number of covered individuals over a specified period of time. Also, a measurement of the quantity and types of services consumed by members of a covered group over a given time period.

Usual fee: See fee.

Usual, Customary and Reasonable Fees: See fee.

Upcode: Reporting a more complicated and/or expensive process than was carried out. Overcoding is another term for it.

Unbundling of procedures: The division of a dental operation into component portions, each with its own charge, so that the total charge to patients who are not covered by a dental benefit plan for the same service is larger than the total charge to patients who are not covered by a dental benefit plan.

V

There are no administrative terms beginning with “V.”

W

Waiting period: The time between starting a new job or enrolling in a dental program and becoming eligible for a certain benefit.

Worker’s compensation: An employee who experiences a work-related illness or injury receives a benefit.

X / Y / Z

There are no administrative terms beginning with “X, Y, or Z.”