Terms
EPO spelled out
What is Exclusive Provider Organization?
1 of these 3 have to be included in the medical plan name to in order for the dental plan to have out of network benefits
What is PPO, HMO POS,RPPO?
Dental plans can be structured to include dental in these 3 ways
What are MSB, OSB or Combo?
Resource guide used to read full descriptions of member benefits.
What is the EOC?
Always use this to search for available providers for our members
What are the Aetna/Liberty websites?
A provider who has advanced education and training in one clinical area of practice.
What is a Specialist?
These plans cover all ADA codes except for a select number of cosmetic, codes medical in Nature, and administrative codes. (These plans will switch names in 2025.)
What are Total/Choice Plans?
Combo plans come with ______ services embedded and the option to add ______ services for an additional premium
What are Preventative and Comprehensive
The workflow is used to also disenroll OSB members on command.
What is the Cancellation/Disenrollment workflow?
All contracted providers must participate in this, in order to be considered INN
What is the Aetna Dental PPO Network?
ADA spelled out
What is American Dental Association?
This type of plan allow members to see any licensed dental provider regardless if they are PAR or NON PAR
What is DMR Plans?
During these 3 "timeframes" OSB can be added
What is during AEP, SEP, or within 30-31 days of effective date?
The system that shows year over year benefits and should reviewed with each call to discuss upcoming changes during AEP
What is the SCP Stars Central Portal?
It is not enough to look up a provider name or group you must always confirm this, to ensure you are properly assisting the member.
What is the Servicing location?
6 names of the types of Scheduled Benefit Plans options in 2025.
What is Preventive, Deluxe, Broad, Choice, Essential, SNP Enhanced?
These plans can cover different levels of comprehensive services from preventative only to Deluxe.
Scheduled Benefits EPO/PPO plans
True or False: Technically, a member can stop paying their OSB premium to end Dental coverage.
True, members OSB will term after a 90 day grace period passes with no payment.
To see where the member stands towards their annual maximums and frequencies.
Why do to go to GPS accumulators?
Providers with this flag is considered Out of Network for dental benefits
What is DENMEDCR
These are dental services are services that are related to the prevention, diagnosis, and treatment of functional and structural diseases of the gums
What is Periodontics?
True or False. Scheduled benefit plans are the only plans with both frequency limits and benefit maximums
True
Dental coverage available to the member is based on these 2 things.
What is Plan selection and Service Area
We will use this resource to look up specific member benefits for their plan based on limitations/frequency limits and it also lists specific covered codes.
What is a schedule of benefits in EOC or ADA codes
?
This Rumba screen will tell you what Net ID's each provider participates in
Provider Summary Screen in EPDB