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Your Guide to Dental Insurance Terms

Your Guide to Dental Insurance Terms

Posted Jul 15, 2013 by Author

In order to buy the best individual dental insurance plan for you and your family, you need to understand exactly what you’re purchasing. However, insurance terminology can come across as vague and confusing. To help bring clarity to your search, we compiled a list of common—and not so common—dental insurance terms and defined everything from agent to waiting period.

If you need additional explanations or assistance with selecting smile-worthy benefits, help is no further than a dentalinsurance.org sales consultant oryour local insurance agent.

Agent: A person licensed to sell insurance products. He or she may be a captive agent authorized to sell a single carrier’s products or an independent agent authorized to sell multiple carriers’ products. See also broker and producer.

Allowable charges: The maximum dollar amount on which benefit payment is based for each dental procedure.

Amalgam: Metallic filling made by combining an alloy of silver, zinc, lead and tin with mercury.

Annual maximum benefit: Maximum dollar amount paid by the dental plan in a calendar year or plan year.

Basic care: Dental procedures to repair and restore individual teeth due to decay, trauma, impaired function, attrition, abrasion or erosion. Basic care services may include fillings (restorations), amalgam restorations, composite restorations, simple extractions, sedative fillings and maintenance prosthodontics such as denture repair, rebase, and reline.

Benefit: The amount payable by a third party toward the cost of various covered dental services or the dental service or procedure covered by the plan.

Bitewing X-ray: An X-ray that reveals the crown and the adjacent tissue of the upper and lower jaws on the same film; it is used to detect decayed areas betweenteeth.

Braces: Metallic bands and appliances used to move teeth for correction of the bite and tooth position.

Bridge: Appliance to replace a missing tooth or teeth attached to and supported by abutment teeth.

Broker: A person licensed and authorized to sell insurance products for multiple carriers; see also agent and producer.

Calendar-year maximum: The maximum amount of benefits payable under the certificate in a calendar year (January 1 through December 31 of the same year).

Caries: Decaying teeth; also known as cavities.

Insurance Carrier: The insurance company that has filed a dental insurance plan/policy with each state’s department of insurance, issues it and contractually assumes the associated risk. Also called the insurer.

Certificate of coverage: A legal document detailing a member or group’s coverage.

Certificateholder: The insured person under the policy.

Certificate of dental insurance: A legal document detailing a member’s group coverage.

Claim: The charges for medical/dental products and services, which are submitted by the provider or policy holder to the insurance company for review.

Coinsurance: The arrangement between the insurance carrier and the insured in which the insurance company pays the specified percentage for a specific class ofcovered services and the remaining percentage is the responsibility of the insured.  For example: You have a PPO dental plan and you go to a PPO provider. Your charges are $100 for services classified under basic care payable at 80 percent, then the insurance company will cover 80 percent or $80 and you will be responsible for the remaining 20 percent or $20.

Composite: White (tooth-colored) plastic filling material of resin and quartz crystals.

Contract fee schedule plan: A dental benefit plan in which participating dentists agree to accept a list of specific fees as the total fees for dental treatment provided. Scheduled plans are similar to HMO medical plans offering low-cost but very limited provider options.

Copay—or copayment: A cost-of-sharing arrangement in which a member pays a specified charge at the time of service; for example, $15 for an office visit.  Dental copays differ from those applied to medical office visits or for prescriptions. A copay on a dental policies is often added cost to the insured that they must pay at the time of service. A copay on adental policy will bring down the overall plan cost (premium).

Coverage: Benefits available to an individual covered under a dental benefit plan.

Covered charge: Services and procedures that are listed in the policy / certificate of insurance and are performed by a licensed dentist.

Covered person: An individual who is eligible for benefits under a dental benefit program.

Covered services: Services for which payment is provided under the terms of the dental benefit contract.

Deductible: The set dollar amount for covered procedures that an insured personmust pay in full in a calendar year before the dental plan pays benefits.

Dentures: Any dental appliance to replace missing natural teeth and surrounding tissues.

Dental insurance: A plan that financially assists in the expense of treatment and care of dental disease and accidents to teeth

Dependents: Generally the insured’s legal spouse and children of covered individual, as defined by terms of the dental benefit contract.

Diagnostic care: Dental services used to detect dental disease. Diagnostic services include X-rays—bitewing and full mouth.

Discount plan: For a membership fee, participants receiveaccess to discounted rates on dental services at participating providers. Members pay providers directly at the time of service. A dental discount plan is not an insurance plan.

Effective date: The date an individual and/or dependents become eligible for benefits under a dental benefit contract; also known as the eligibility date or official plan start date.

Endodontics (root canals): Dental speciality concerned with the treatment of diseases of the dental pulp (nerves, blood vessels, etc., within the tooth).

Eruption: When a new tooth comes in, it erupts when it breaks the surface of the gums and you can see it.

Explanation of benefits (EOB): The EOB is not a bill; it details how the claim was processed and indicates the portion of the claim paid to the dentist and the portion of the claim that the insured needs to pay (if applicable).

The plan carrier sends an EOB to the insured and the dental provider detailing how each claim is covered under the policy. If a claim is not fully covered by the insurance plan there will be a balance for which the dental office will bill the insured.

Exclusions: Dental services not covered under a dental benefit program.

Extraction: Separation and surgical removal of a tooth from its surrounding tissue.

Family deductible: The maximum paid by a family. For example, with a $50 individual deductible and $150 family deductible, a four-member family would need to fulfill three separate $50 deductibles before the family deductible is satisfied and a fourth member of the family plan could receive benefits without paying into the deductible.

Fee schedule: A list of the charges established or agreed to by a dentist for specific dental services.

Filling: Material used to fill a cavity in a tooth; the substance may be gold, silver, amalgam, copper amalgam, acrylic resins, porcelain or cement.

Full mouth X-Ray: Usually consists of panoramic film or full series.

Gingivitis: Inflammation of the gum tissue.

Implant: A device of metal or other foreign material that is surgically placed into or on the upper or lower bone to support a crown, bridge or partial orfull denture.

Impacted tooth: Tooth that has not erupted and is embedded in the jaw.

Indemnity - individual dental insurance: A dental plan that allows you to choose your own individual or family dentist. Claims are reimbursed based on the reasonable and customary fee for charges in the provider’s area rather than a network fee schedule. This is a good option for those who will not or cannot go to an in-network provider since claims are reimbursed closer to the actual dentist’s charge.

An insured individual and/or his or her employer pay a monthly premium to the insurance company, which pays the dental provider on a traditional fee-for-service basis.

Individual deductible: Dollar amount of eligible expenses that a covered person must pay each year before covered services can be put towards the dental plan.

Inlay: A porcelain or metal restoration to be inserted into a previously prepared cavity in a tooth and retained with cement.

Insurer: An organization that bears the financial risk for the cost of defined categories or services for a defined group of beneficiaries.

In-network provider: A dentist who is under contract with the insurance company or its subcontracted vendor, such as a PPO network associated with the dental plan.

Insured/insured person/member: The individual named on the schedule of benefits as the insured who has coverage under the policy.

Lingual surface: Surface of the tooth toward the tongue.

Limitations: Restrictive conditions stated in a dental benefit contract, such asage, length of time covered, and waiting periods, which affect an individual's coverage. The contract may also exclude certain benefits or services, or it may limit the extent or conditions under which certain services are provided.

Major services: Dental procedures concerned with the restoration of teeth by cast restorations such as inlays, onlays, crowns, or veneers; major services mayinclude endodontics (root canals), periodontics (tissue/bone treatment), aswell as oral surgery.

Maximum benefit: The maximum dollar amount a program will pay for all covered services toward the cost of dental care incurred by an individual or family in a specific period, usually a calendar year.

Member: An individual enrolled in a dental benefit program.

Occlusal X-ray: An intraoral film showing the lingual surfaces of the teeth and a portion of the hard palate.

Onlay: Restoration that is extended to cover the entire incisal or occlusal surface of the tooth; often used to restore lost tooth structure and increase the height of the tooth.

Oral surgery: Dental specialty concerned with the surgical procedures in and around the mouth and jaw.

Orthodontic services: A specialty concerned with the correction of improper alignment of the upper and lower teeth.

Out-of-network provider: A provider who is not under contract with the PPO Network associated with a particular individual dental plan.

Overbite: Misalignment of the upper and lower teeth or jaws in which the upper teeth overlap the lower teeth when the mouth is closed.

Participating dentist: A dentist that is in the PPO Network associated with a particular individual dental plan.

Palate: The roof of the mouth

Pedodontics: Dental specialty concerned with the prevention and treatment of dental disorders in children

Periodontics: Dental specialty concerned with diseases of the gums and other supportive structures of the teeth

Plaque: Sticky substance composed of secretions containing bacteria, dead tissue cells and debris. When this harmful substance accumulates on teeth, it is considered to be an initiation factor in gingival inflammation.

Point of service: Arrangements in which patients with a managed care dental plan have the option of seeking treatment from an "out-of-network" provider. The reimbursement for the patient is usually based on a low table of allowances, with significantly reduced benefits than if the patient had selected an "in-network" provider.

Policy: The insurance contract providing the benefits described and issued to the policyholder.

Policyholder: The group or individual in whose name the policy is issued, as shown on the schedule of benefits.

Porcelain: Restorative material of various types of fused (molten) glasses; used to make teeth, facings, jackets and dentures.

PPO service area: The geographical area in which the insurance carrier has arranged to provide PPO services to covered persons.

Preauthorization: Statement by a third-party payer indicating that proposed treatment will be covered under the terms of the benefit contract.

Precertification: Confirmation by a third-party payer of a patient’s eligibility for coverage under a dental benefit program.

Predetermination: An administrative procedure that may require the dentist to submit a treatment plan to the third party before treatment is begun. The third party usually returns the treatment plan indicating one or more of the following:patient's eligibility, guarantee of eligibility period, covered services, benefit amounts payable, application of appropriate deductibles, co-paymentand/or maximum limitation. Under some programs. predetermination by the third party is required when covered charges are expected to exceed a certain amount, such as $200.

Pre-existing conditions: Oral health condition of an enrollee that existed before his or her enrollment in a dental plan.

Preferred provider organization (PPO): Dental insurance plans that contract with a network of dentists and negotiate discounted rates for plan participants. When care is sought out of network, it is often covered but will cost more out of pocket because certain plans reimburse based on the in-network maximum allowable charge or fee schedule.Out-of-network dentists have not agreed to charge these amounts and may charge higher fees. The difference between the allowed amount and the dentist’s actual charge is the responsibility of the insured.

Premium: The amount charged by a the insurance company for coverage of a level of benefits for a specified time. Dental premiums are usually payable monthly, quarterly or annually, and you may save money compared to the monthly rate if you select a quarterly or annual payment option.

Prepaid dental plan: A method of financing the cost of dental care for a defined population, in advance of receipt of services.

Prescription drugs: Drugs that may only be dispensed by written prescription under federal law, and approved for general use by the Food and Drug Administration.

Preventive dentistry: Refers to the procedures in dental practice and health programs that prevent the occurrence of oral diseases.

Preventive care: Dental procedures concerned with the prevention of dental diseases by protective and educational measures; preventive services may include examination, cleanings, X-rays and fluoride.

Prophylaxis: The cleaning and scaling of teeth.

Prosthodontic services: Dental specialty concerned with the restoration of missing teeth by artificial needs.

Reasonable and customary charge: The most common charge for similar professional services, drugs, procedures, devices, supplies or treatment within the geographic area in which the charge is incurred.

Recession: Gradual drawing of tissue from its normal position; for example, the recession of the gum away from the tooth.

Resin: Organic materials, usually named according to chemical composition,physical structure or means of curing; frequently referred to as “plastic.”

Reimbursement: Payment made by a third party to a beneficiary or to a dentist on behalf of the beneficiary, toward repayment of expenses incurred for a service covered by the contractual arrangement.

Retainer: Appliance to prevent collapse of the dental arch.

Root canal therapy (endodontic therapy): Treatment of a tooth having damaged pulp, usually performed by removing the pulp chamber and root canals and filling these spaces with inert sealing material.

Scale: To remove tarter and stains from teeth with special dental instruments.

Schedule of allowances: A list of covered services with an assigned dollar amount that represents the total obligation of the plan with respect to payment for such services, but does not necessarily represent the dentist's full fee for that service.

Schedule of benefits: A listing of the services for which payment will be made by a third-party payer, without specification of the amount to be paid.

Sealant: Material applied to the chewing surface of a tooth to prevent decay.

Silicate: Materials developed for dental restorations that have a lesser amount of precious metals.

Surgical extraction: Removal of a tooth by surgical methods.

Tarter: Hard deposit that forms on the teeth when plaque hardens.

Termination date: The date on which the dental benefit contract expires or the date an individual ceases to be eligible for benefits.

Third-party administrator: An individual or company contracted by the insurance carrier to hire some aspect of its operation, such as claims processing. Commonly called a TPA.

Usual, customary and reasonable (UCR) plan: A dental benefit plan that determines benefits based on usual, customary and reasonable fee criteria.

Veneer crown: full crown that has one or more surfaces covered by tooth-colored plastic or porcelain.

Waiting period: The time period during which a dental plan participant must wait before certain benefits will be paid. Waiting periods typically start on the plan’s effective date.

Find more information about dental insurance offered by The IHC Group or obtain quotes from The IHC Group and Humana at www.dentalinsurance.org.