Terms 1
Eligibility date
The effective date of dental coverage
A list of charges for dental services and procedures established by the dentist or a dental benefits provider and are mutually agree on
Fee Scheduling
Down Coding
A method of changing a reported benefits code by third party payers to reflect a lower cost for the procedure.
The portion of the service fee that remains after payment is made by the dental benefit plan and is payable by the patient
Copayment
Current dental terminology
A Standardized list of terms and codes established by the ADA for the purpose of consistency in reporting dental benefits plans
Deductible
The fee that the patient is responsible for paying before the insurance company will consider payment of the balance of charges
A method of financial assistance that helps pay for specified procedures and services concerning dental disease and accidental injury to the oral structure.
Dental insurance
Dependent
Persons who are covered under another person's dental policy
The total amount of dental benefits that will be paid for an individual or family for the purpose of dental services and procedures.
Maximum benefit
A dentist who has contracted with a dental benefits organization to provide dental care to specific
Participating dentist
Non-participating dentist
A dental professional who is not under contract with a dental benefit's plan to provide dental services and procedures to enrollees
An amount the patient is responsible for paying such as coinsurance, copayments, deductibles and costs above the annual maximum.
Out of pocket
Replacement clause
State s that an insurance company will not pay to replace a crown, bridge, partial, denture or implant until a specific time has passed. it is primarily every 5 years but can range from 3 to 10 years.
It goes from January thru December and starts over again
Calendar year
Insured
A person who has enrolled with an insurance policy
Maximum fee schedule
The total acceptable fee for a dental service or procedure that can be charged by a dental provider under a specific dental benefits plan.
The holder of the dental benefits. usually this is the person whose name is on the policy and additional coverage is extended to the spouse and children. Other term used to describe the subscriber are enrollee, insured, and certified holder
Subscriber
Preauthorization's
Confirmation by a dental benefits plan that a pretreatment plan has been authorized for payment according to the patients group policy
What organization issues the current dental terminology codes
The American Dental Association
preexisting conditions
A clause in most entail insurance policies that limits coverage for conditions that existed before the patient enrolled in the plan.
Claim
Also known as the attending dentists statement. claims are a method used to request payment or authorization for treatment. Each claim provides necessary information about the patient, treating dentist, and treatment
States that an insurance company will not pay to replace a missing tooth that was missing prior to coverage
Missing tooth clause
Family Deductible
A deductible that can be satisfied when combined deductibles of the family members deductible
Date on which the patient is no longer eligible for dental benefits based on expiration of dental contract or termination of the patients employment.
Expiration Date
Exclusions
The option in a dental benefits program to exclude dental services and procedures