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A |
B |
C |
D |
E |
F |
G |
H |
I |
J |
K |
L |
M |
N |
O |
P |
Q |
R |
S |
T |
U |
V |
W |
X |
Y |
Z
A
Allowable Charges: The maximum
dollar amount on which benefit payment is based for each
dental procedure.
B
Beneficiary:
A person who receives benefits under a dental
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 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.
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.
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.
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.
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.
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 plan.
Exclusions:
Dental services not covered under a dental
benefit program.
Expiration Date: 1)
the date on which the dental 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
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.
*1999 American Dental
Association. For more
information go to AMERICAN DENTAL ASSOCIATION at
www.ada.org |
