A
Allowable
Charges:
The maximum dollar amount on which dental plan benefit
payment is based for each dental procedure.
B
Beneficiary: A person who receives benefits under a dental
plan benefit contract.
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.
Benefit
Booklet: A booklet or pamphlet provided to the subscriber
which contains a general explanation
of the benefits and related provisions
of the dental benefit program.
Also known as a "Summary Dental Plan Descriptions."
C
Capitation:
A capitation
program is one in which a dentist or
dentists contract with programs' sponsor
or administrator to provide all or most
of the dental services covered under
the program to subscribers in return
for payment on a per-capita basis. Dental plans!
Certificate
Holder: The
person, usually the employee or responsible
party, who represents the family unit
covered by the dental benefit program;
other family members are referred to
as "dependents."
Closed
Panel: A closed panel dental benefit plan exists
when patients eligible to receive benefits
can receive them only if service are
provided by dentists who have signed
an agreement with the benefit plan to
provide treatment to eligible patients.
As a result of the dentist reimbursement
methods characteristic of a closed panel
plan, only a small percentage of practicing
dentists in a given geographical area
are typically contracted by the plan
to provide dental services. Dental Plans
Contract
Dentist: A practitioner who contractually agrees to provide
services under special terms, conditions
and financial reimbursement arrangements.
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. Dental Plans
Coverage:
Benefits available
to an individual covered under a dental
benefit plan.
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. Dental Plans
D
Dental
Benefits Organization:
Any organization
offering a dental benefit plan.
Also known as dental plan organization.
Dental
Benefit Plan:
Entitles covered
individuals to specified dental services
in return for a fixed, periodic payment
made in advance of treatment.
Such plans often include the use of
deductibles. coinsurance, and/or maximums
to control the cost of the program to
the purchaser.
Dental
Benefit Program:
The specific
dental benefit plan being offered to
enrollees by the sponsor.
Dental
Insurance: A plan that financially assists in the expense
of treatment and care of dental disease
and accidents to teeth.
Dental
Prepayment:
A method of
financing the cost of dental services
prior to their receipt. Dental Plans
Dependents: Generally spouse and children of covered individual,
as defined by terms of the dental benefit
contract.
E
Eligibility
Date: The
date an individual and/or dependents
become eligible for benefits under a
dental benefit contract. Often
referred to as effective date.
Enrollee: Individual covered by a benefit dental plan.
Exclusions: Dental services not covered under a dental plan benefit
program.
Expiration
Date: 1) the date on which the dental plan benefit contract
expires.
2) The date
and individual cease to be eligible
for benefits.
F
Fee-for-Service: A method of paying practitioners on a service-by-service
rather than a salaried or capitated
basis.
Fee
Schedule: A
list of the charges established or agreed
to by a dentist for specific dental
services.
H
Health
Maintenance Organization (HMO):
A legal entity
that accepts responsibility and financial
risk for providing specified services
to a defined population during a defined
period of time at a fixed price.
An organized system of health care delivery
that provides comprehensive care to
enrollees through designated providers.
Enrollees are generally assessed a monthly
payment for health care services and
may be required to remain in the program
for a specified amount of time.
I
Indemnity
Plan: A dental plan where a third-party payer provides
payment of an amount for specific services,
regardless of the actual charges made
by the provider. Payment may be
made either to enrollees or, by assignment,
directly to dentists. Schedule
of allowances, table of allowances,
or reasonable and customary plans are
examples of indemnity plans.
Insurer:
An organization
that bears the financial risk for the
cost of defined categories or services
for a defined group of beneficiaries.
Insured: Person covered by the dental plan program.
L
Liability: An obligation for a specified amount or action.
Limitations: Restrictive conditions stated in a dental benefit contract, such as age,
length of time covered, and waiting
periods, which affect an individual's
or group'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.
M
Managed Care: Refers to a cost containment system that directs the utilization of health
benefits by:
a. restricting the type, level and frequency of treatment;
b. limiting the access to care; and
c. controlling the level of reimbursement for services.
Maximum
Allowance:
The maximum dollar amount a dental program
will pay towards the cost of a dental
service as specified in the program's
contract provisions, e.g., UCR. Table
of Allowances.
Maximum
Benefit:
The maximum dollar amount a program
will pay toward the cost of dental care
incurred by an individual or family
in a specific period, usually a calendar
year.
Maximum
Fee Schedule:
A compensation arrangement in which
a participating dentist agrees to accept
a prescribed sum as the total fee for
one or more covered services.
Member: An individual enrolled in a dental benefit program.
N
Necessary
Treatment:
A necessary dental procedure or service
as determined by a dentist, to either
establish or maintain a patient's oral
health. Such determinations are
based on the professional diagnostic
judgment of the dentist, and the standards
of care that prevail in the professional
community.
Noncontributory
Program:
A method of payment for group coverage
in which all of the monthly premium
for the program is paid by the sponsor.
Nonduplication
of Benefits:
This may apply if a subscriber is eligible
for benefits under more than one plan.
A dental benefit contract provision
relieving the third-party payer of liability
for cost of services if the services
are covered under another program.
Distinct from a coordination of benefits
provision, because reimbursement would
be limited to the greater level allowed
by the two plans, rather than a total
of 100% of the charges. Also referred
to as "benefit-less-benefit" or "carve-out".
Nonparticipating
Dentist:
Any dentist who does not have
a contractual agreement with a dental
benefit organization to render dental
care to members of dental benefit program.
O
Open
Enrollment:
The annual period in which employees
can select from a choice of benefit
programs.
P
Participating
Dentist:
Any dentist who has a contractual agreement
with a dental benefit organization to
render care to eligible persons.
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.
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-payment
and/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
which existed before his/her enrollment
in a dental program.
Preferred
Provider Organization (PPO):
A formal agreement between a purchaser
of a dental benefit program and a defined
group of dentists for the delivery of
dental services to a specific patient
population, as an adjunct to a traditional
plan, using discount fees for cost savings.
Premium: The
amount charged by a dental benefit organization
for coverage of a level of benefits
for a specified time.
Prepaid
Dental Plan:
A method of financing the cost of dental
care for a defined population, in advance
of receipt of services.
Prevailing
Fee:
Term used by some dental benefit
organizations to refer to the fee most
commonly charged for a dental service
in a given area.
Preventive
Dentistry:
Refers to the procedures in dental
practice and health programs which prevent
the occurrence of oral diseases.
Purchaser: Program
sponsor, often employer or union, that
contracts with the dental benefit organization
to provide dental benefits to an enrolled
population.
Q
Quality
Assessment:
The measure of the quality of
care provided in a particular setting.
Quality
Assurance:
The assessment or measurement of the
quality of care and the implementation
of any necessary changes to either maintain
or improve the quality of care rendered.
R
Reasonable
and Customary (R&C) Plan:
A dental benefit plan that determines
benefits based only on "Reasonable and
Customary" fee criteria.
Reasonable
Fees:
The fee charged by a dentist
for a specific dental procedure that
has been modified by the nature and
severity of the condition being treated
and by any medical or dental complications
or unusual circumstances, and therefore
may differ from the dentist's "usual"
fee or the benefit administrator's "customary"
fee.
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.
S
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.
Subscriber: The person, usually the employee, who represents the family unit in relation
to the dental benefit program.
This term is most commonly used by service
corporation plans.
Surcharge: A stated dollar amount paid to the dentist by the beneficiary, in addition
to other reimbursement received by third-party
payer(s).
T
Table
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.
Termination
Date: 1)
the date on which the dental benefit
contract expires.
2) The date and individual cease to be eligible for benefits.
Third
Party:
The party to a dental benefit
contract that may collect premiums,
assume financial risk, pay claims, and/or
provide other administrative services
Third-Party
Administrator (TPA):
Claims payer who assumes responsibility
for administering health benefits plans
without assuming any financial risk.
Some commercial insurance carriers and
Blue Cross/ Blue Shield plans also have
TPA operations to accommodate self-funded
employers seeking administrative services
only (ASO) contracts.
Third-Party
Payer: An
organization other than the patient
(first party) or health care provider
(second party) involved in the financing
of personal health services.
U
Usual,
Customary and Reasonable (UCR) Plan:
A dental benefit plan that determines
benefits based on "Usual, Customary,
and Reasonable: fee criteria.
Usual
Fee: The fee that an individual dentist most frequently charges for a given
dental service.
Utilization: 1) The extent to which the members of a covered group use a program over
a stated period of time; specifically
measured as a percentage determined
by dividing the number of covered individuals
who submitted one or more claims by
the total number of covered individuals.
2) An expression of the number and types
of services used by the members of a
covered group over a specified period
of time.
W
Waiting
Period:
The period between employment or enrollment
in a dental program and the date when
a covered person becomes eligible for
benefits.
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