Insurance 101
Is the person who is at the center of our orthodontic eligibility verification.
PATIENT
The patient can only receive orthodontic benefits ONCE PER LIFETIME while on their policy.
Lifetime Maximum (LTM)
Represents the owner of the insurance policy.
Subscriber
Benefit that renews every calendar year.
Annual Maximum
The business that employs the doctors and staff providing services to patients.
Practice
The dentist who actually performs the treatment.
Treating Provider
Is the percentage of allowable costs that the patient and insurance company are each responsible for.
Coinsurance
The person who provides orthodontic services to patients.
Provider
Is the amount the patient pays each year for eligible services before their health plan begins to share in the cost of covered services.
Deductible
Is the date that the policy began covering insurance benefits.
Policy Effective Date
Refers to a period of time that a plan needs to be active before it begins covering orthodontic benefits.
Waiting Period
Determines which plan has the primary responsibility for paying for treatment.
Plan Priority
Refers to the entity who receives insurance payments.
Assignment of Benefits (AOB)
The schedule on which an insurance carrier issues payment.
Payment Distribution
This includes treatments to correct dental issues causing pain, difficulty eating, and other quality of life concerns.
Medically Necessary
Refers to how multiple policies work together to pay for a patient's treatment.
Coordination of Benefits (COB)
A document issued by the carrier to the provider to estimate how much the insurance policy will pay in total.
Pre-determination
2 types of Payment Distribution
Automatic & Continuation
They rely on us to get their eligibility verified with the insurance company.
Patient
2 Types of Network Participation
INN & OON
Refers to an ortho provider's agreement to provide services to members of a specific health insurance plan within a certain geographic area. This agreement is outlined in a contract between the provider and the insurance company, which includes the terms and conditions for the services offered.
NETWORK PARTICIPATION
They rely on us to accurately and efficiently verify eligibility so they can focus on providing quality patient care.
Providers
A policy network type that tends to have higher premiums, but more flexibility in choice of providers.
PPO (Preferred Provider Organizations)
A policy network type that has lower premiums but fewer choices in providers.
DHMO (Dental Health Maintenance Organization)
It occurs when a provider is not contracted with the carrier that is directly covering the insured, but that carrier/group plan is using another insurance entity’s network fees.
INDIRECT NETWORK PARTICIPATION