IntroductionThere are many terms used daily by dentists and their staff in the course of delivering care to patients, maintaining patient records and preparing claims. Many terms are familiar, especially to experienced individuals. New dentists and staff, however, may not be as familiar – and over time new terms come into use and old terms are revised for clarity.
Glossary – Administrative terms
(Words and terms in bold are defined within this glossary. Click a letter to jump to that section.)
administrative costs: Overhead expenses incurred in the operation of a dental benefit program, exclusive of costs of dental services provided.
administrative services only (ASO): An arrangement under which a third party, for a fee, processes claims and handles paperwork for a self-funded group. This frequently includes all insurance company services (actuarial services, underwriting, benefit description, etc.) except assumption of risk.
allowable charge: The maximum dollar amount on which benefit payment is based for each dental procedure as calculated by the third-party payer.
alternate benefit: A provision in a dental plan contract that allows the third-party payer to determine the benefit based on an alternative procedure that is generally less expensive than the one provided or proposed.
ANSI/ADA/ISO: Acronyms for organizations that administer or develop national and international standards. ANSI (American National Standards Institute) is the national organization established for the purpose of accrediting and coordinating product standards development activities in the United States. It is not a US government agency. The ADA (American Dental Association) is a national standards development organization accredited by ANSI. ISO (International Organization for Standardization) is a worldwide federation of national standards bodies. The results of ISO technical work are published as International Standards. Efforts in the United States directed toward the development of ISO standards are channeled through ANSI.
any willing provider: Legislation that requires managed care organizations (MCOs), such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs) to contract with any providers who are willing to meet the terms of the contract.
appeal: A formal request that an insurer review denied or unpaid claims for services or supplies provided. An appeal can be filed by a healthcare provider or a patient in an attempt to recover reimbursement from a third-party payer such as a private insurance company.
assignment of benefits: A procedure whereby a beneficiary/patient authorizes the administrator of the program to forward payment for a covered procedure directly to the treating dentist.
attending dentist’s statement: An obsolete term for the ADA Dental Claim Form. See claim form.
audit: An examination of records or accounts to check their accuracy. A post-treatment record review or clinical examination to verify information reported on claims.
bad faith insurance practices: The failure to deal with a beneficiary of a dental benefit plan fairly and in good faith; or an activity which impairs the right of the beneficiary to receive the appropriate benefit of a dental benefits plan or to receive them in a timely manner. Some examples of potential bad faith insurance practices include: evaluating claims based on standards which are significantly at variance with the standards of the community; failure to properly investigate a claim for care; and unreasonably and purposely delaying and/or withholding payment of a claim. See prompt payment laws.
balance billing: Billing a patient for the difference between the dentist’s actual charge and the amount reimbursed under the patient’s dental benefit plan.
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 that contains a general explanation of the benefits and related provisions of the dental benefit program. Also known as a Summary Plan Description.
benefit plan summary: The description or synopsis of employee benefits as required by ERISA that is to be distributed to the employees.
birthday rule: When a dependent child’s parents both have dental coverage, this rule states that the primary program (the one which pays first) is the one covering the parent whose month and day of birth falls first in the calendar year. The birthday rule is the most common rule for determining primary v. secondary coverage, but it may be superseded by a court order such as a divorce agreement.
bundling of procedures: The systematic combining of distinct dental procedure codes by third-party payers that results in a reduced benefit for the patient/beneficiary.
cafeteria plan: Employee benefit plan in which employees select their medical insurance coverage and other nontaxable fringe benefits from a list of options provided by the employer. Cafeteria plan participants may receive additional, taxable cash compensation if they select less expensive benefits.
capitation: A capitation program is one in which a dentist or dentists contract with the 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.
Centers for Medicare and Medicaid Services (CMS): The federal agency responsible for administering the Medicare, Medicaid, State Children’s Health Insurance Program (SCHIP), HIPAA, and the Clinical Laboratory Improvement Amendments (CLIA) programs. CMS is part of the U.S. Department of Health and Human Services.
claim: A request for payment under a dental benefit plan; a statement listing services rendered, the dates of services, and itemization of costs. The completed request serves as the basis for payment of benefits.
claim form: A form, paper or electronic, used to report dental procedures to a third-party payer in order to file for benefits under a dental benefit program. The paper claim form was developed by the American Dental Association.
claimant: Person or authorized provider who files a claim for benefits. Patient or certificate holder who files a claim for benefits.
claims payment fraud: The intentional manipulation or alteration of facts or procedure codes submitted by a treating dentist resulting in a lower payment to the beneficiary and/or the treating dentist than would have been paid if the manipulation had not occurred.
claims reporting fraud: The intentional misrepresentation of material facts concerning treatment provided and/or charges made, in that this misrepresentation would cause a higher payment.
closed panel: A dental insurance benefit plan which requires the eligible patients to receive their dental care from a specific dentist who has contractually agreed to the terms, payments and benefits of the plan. Usually only a limited number of dentists in an area are allowed to participate in these types of plans.
COB: See coordination of benefits.
coinsurance: A provision of a dental benefit program by which the beneficiary shares in the cost of covered services, generally on a percentage basis. The percentage of a covered dental expense that a beneficiary must pay (after the deductible is paid). A typical coinsurance arrangement is one in which the third party pays 80% of the allowed benefit of the covered dental service and the beneficiary pays the remainder of the amount due the dentist. Percentages vary and may apply to table of allowance plans; maximum allowable benefit plans and direct reimbursement programs.
Consolidated Omnibus Budget Reconciliation Act (COBRA): Legislation relative to mandated benefits for all types of employee benefit plans. The most significant aspects within this context are the requirements for continued coverage for employees and/or their dependents for 18 months who would otherwise lose coverage (30 months for dependents in the event of the employee’s death).
contract: A legally enforceable agreement between two or more individuals or entities that confers rights and duties on the parties. Common types of contracts include: 1) contracts between a dental benefit organization and an individual dentist to provide dental treatment to members of a benefit plan. These contracts define the dentist’s duties both to beneficiaries of the dental benefit plan and the dental benefit organization, and usually define the manner in which the dentist will be reimbursed; and 2) contracts between a dental benefit organization and a group plan sponsor. These contracts typically describe the benefits of the group plan and the rates to be charged for those benefits.
contract term: Usually a 12 months period of time for which a contract is written and during which a group’s deductibles, maximums and other provisions apply. This may or may not be the same as a calendar year. Also known as the benefit year.
contributory program: A dental benefit program in which the enrollee shares in the monthly premium of the program with the program sponsor (usually the employer). Generally done through payroll deduction. coordination of benefits
coordination of benefits (COB): A method of integrating benefits payable for the same patient under more than one plan. Benefits from all sources should not exceed 100% of the total charges.
copayment: Beneficiary’s share of the dentist’s fee after the benefit plan has paid
cost containment: Features of a dental benefit program or of the administration of the program designed to reduce or eliminate certain charges to the plan.
cost sharing: The share of health expenses that a beneficiary must pay, including the deductibles, copayments, coinsurance, and charges over the amount reimbursed by the dental benefit plan.
coverage: Benefits available to an individual covered under a dental benefit plan.
covered charges: Dentists’ fees that are reimbursed in whole or in part under the conditions of the dental benefit plan, subject to all the terms and conditions of the agreement or insurance policy. Reimbursement amounts are subject to any contractual agreements, exclusions and limitations.
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 amount of dental expense for which the beneficiary is responsible before a third party will assume any liability for payment of benefits. Deductible may be an annual or one-time charge, and may vary in amount from program to program. See family deductible.
dental benefit organization: Any organization offering a dental benefit plan. Also known as dental plan organization.
dental benefit program: The specific dental benefit plan being offered to enrollees by the sponsor.
dental enrollment credentialing: A formal process that defines the standards and requirements for participation in third-party programs. The process verifies professional qualifications in order to allow licensed dentists to provide services to members of these programs.
dental home: The ongoing relationship between the dentist who is the Primary Dental Care Provider and the patient, which includes comprehensive oral health care, beginning no later than age one, pursuant to ADA policy.
dental prepayment: A method of financing the cost of dental services prior to receiving the services.
dentistry: The evaluation, diagnosis, prevention and/or treatment (nonsurgical, surgical or related procedures) of diseases, disorders and/or conditions of the oral cavity, maxillofacial area and/or the adjacent and associated structures and their impact on the human body; provided by a dentist, within the scope of his/her education, training and experience, in accordance with the ethics of the profession and applicable law.
dependents: Generally spouse and children of covered individual, as defined by terms of the dental benefit contract.
direct reimbursement: A self-funded program in which the individual is reimbursed based on a percentage of dollars spent for dental care provided, and which allows beneficiaries to seek treatment from the dentist of their choice.
downcoding: A third-party payer claim adjudication process that uses a procedure code that is different from the one reported on the claim so that the reimbursement amount is less than would be allowed for the submitted code.
DRGs (diagnosis related groups): A system of classifying hospital patients on the basis of diagnosis, consisting of distinct groupings. A DRG assignment to a case is based on the patient’s 1) principal diagnosis; 2) treatment procedures performed; 3) age; 4) gender; and 5) discharge status.
dual choice program: A benefit package from which an eligible individual can choose to enroll in either an alternative dental benefit program or a traditional dental benefit program.
Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT): A federal program that provides comprehensive health care for children through periodic screenings, diagnostic and treatment services. ECF: See extended care facility.
eligibility date: The date an individual and/or dependents become eligible for benefits under a dental benefit contract. Often referred to as effective date.
eligible person: See beneficiary.
Employment Retirement Income Security Act (ERISA): A federal act, passed in 1974, which established new standards and reporting/disclosure requirements for employer-funded pension and welfare benefit programs. To date, self-funded health benefit plans operating under ERISA have been held to be exempt from most state insurance laws, although the courts have held that the states can regulate the medical care provided under such plans, as by requiring mandatory review of adverse HMO determinations.
endodontics: Endodontics is the branch of dentistry which is concerned with the morphology, physiology and pathology of the human dental pulp and periradicular tissues. Its study and practice encompass the basic and clinical sciences including biology of the normal pulp, the etiology, diagnosis, prevention and treatment of diseases and injuries of the pulp and associated periradicular conditions.
endodontist: A dental specialist who limits his/her practice to treating disease and injuries of the pulp and associated periradicular conditions.
enrollee: Individual covered by a benefit plan. See beneficiary.
entity: Something that exists as a particular and discrete unit. Persons and corporations are equivalent entities under the law.
EOB: See explanation of benefits.
ERISA: See Employment Retirement Income Security Act.
established patient: A patient who has received professional services from a dentist or another dentist of the same specialty who belongs to the same group practice, within the past three years, subject to state laws.
Evidence-Based Dentistry: An approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific data relating to the patient’s oral and medical condition and history, with the dentist’s clinical expertise and the patient’s treatment needs and preferences.
exclusions: Dental services not covered under a dental benefit program.
Exclusive Provider Organization (EPO): A type of preferred provider organization under which employees must use providers from the specified network of dentists to receive coverage; there is no coverage for care received from a non-network provider except in an emergency situation.
expiration date: In dentistry, the date on which the dental benefit contract expires; the date an individual ceases to be eligible for benefits.
explanation of benefits: A written statement to a beneficiary from a third-party payer, after a claim has been adjudicated, indicating the charges covered or not covered by the dental benefit plan.
extended care facility: A facility such as a nursing home which is licensed to provide 24-hour nursing care service in accordance with state and local laws. Several levels of care may be provided–skilled, intermediate, custodial, or any combination.
extension of benefits: Extension of eligibility for benefits for covered services, usually designed to ensure completion of treatment commenced prior to the expiration date. Duration is generally expressed in terms of days.
family deductible: A deductible that is satisfied by combined expenses of all covered family members. For example, a program with $25 deductible may limit its application to a maximum of three deductibles, or $75 for the family, regardless of the number of family members. See deductible.
fee: The monetary value ascribed to a procedure delivered by a dentist to a patient. There are various terms that include the word or concept of a fee that are defined as follows.
full fee“The fee for a service that is set by the dentist, which reflects the costs of providing the procedure and the value of the dentist’s professional judgment. A contractual relationship does not change a dentist’s full fee. It is always appropriate to report the full fee for each service reported to a third party payer.
maximum plan benefit “ The reimbursement level determined by the administrator of a dental benefit plan for a specific dental procedure. This may vary widely by geographic region or by benefit plans within a region.
Usual, Customary and Reasonable Fees“These are three separate terms that are often incorrectly used interchangeably, synonymously or as a single term abbreviated as “UCR” when describing dental benefit plans describe fees. The ADA recommends not using this term.
fee-for-service“A method of reimbursement by which the dentist establishes and expects to receive his or her full fee for the specific service(s) performed.
fee schedule“A list of the charges established or agreed to by a dentist for specific dental services.
flexible benefits: A benefit program in which an employee has a choice of credits or dollars for distribution among various benefit options, e.g., health and disability insurance, dental benefits, childcare, or pension benefits. See cafeteria plans; flexible spending account.
flexible spending account: Employee reimbursement account primarily funded with employee designated salary reductions. Funds are reimbursed to the employee for health care (medical and/or dental), dependent care, and/or legal expenses, and are considered a nontaxable benefit.
freedom of choice: The concept that a patient has the right to choose any licensed dentist to deliver his or her oral health care without any type of coercion.
full fee: see fee.
gate keeper system: A managed care concept used by some alternative benefit plans, in which enrollees select a primary care dentist, usually a general practitioner or pediatric dentist, who is responsible for providing non-specialty care and managing referrals, as appropriate, for specialty and ancillary care.
Health Care Financing Administration (HCFA): See Centers for Medicare and Medicaid Services. Health Insurance Portability and Accountability Act (HIPAA) of 1996: A federal law that includes Administrative Simplification Provisions that require all health plans, including ERISA, as well as health care clearinghouses and any dentist who transmits health information in an electronic transaction, to use a standard format. The HIPAA standard electronic dental claim also requires use of the ADA’s Code on Dental Procedures and Nomenclature code set. Paper transactions are not subject to this requirement.
Health Insurance Portability and Accountability Act (HIPAA) of 1996: A federal law that includes Administrative Simplification Provisions that require all health plans, including ERISA, as well as health care clearinghouses and any dentist who transmits health information in an electronic transaction, to use a standard format. The HIPAA standard electronic dental claim also requires use of the ADA's Code on Dental Procedures and Nomenclature code set. Paper transactions are not subject to this requirement.
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.
hold harmless clause: A contract provision in which one party to the contract promises to be responsible for liability incurred by the other party. Hold harmless clauses frequently appear in the following contexts:
1) Contracts between dental benefit organizations and an individual dentist often contain a promise by the dentist to reimburse the dental benefit organization for any liability the organization incurs because of dental treatment provided to beneficiaries of the organization’s dental benefit plan. This may include a promise to pay the dental benefit organization’s attorney fees and related costs; and
2) Contracts between dental benefit organizations and a group plan sponsor may include a promise by the dental benefit organization to assume responsibility for disputes between a beneficiary of the group plan and an individual dentist when the dentist’s charge exceeds the amount the organization pays for the service on behalf of the beneficiary.
If the dentist takes action against the patient to recover the difference between the amount billed by the dentist and the amount paid by the organization, the dental benefit organization will take over the defense of the claim and will pay any judgments and court costs.
inappropriate fee discounting practices: Intentionally engaging in practices which would force a dentist, who does not have a participating provider agreement, to accept discounted fees or be bound by the terms and conditions set forth in the participating provider contract.
Some examples of inappropriate fee discounting practices include: issuing reimbursement checks which, upon signing, result in the dentist accepting the amount as payment in full; using claim forms which, upon signing, require the dentist to accept the terms of the plan’s contract; issuing insurance cards which state that the submittal of a claim by a dentist means that he or she accepts all terms and conditions set forth in the participating provider contract; and sending communications to patients of nonparticipating dentists which state that he or she is not responsible for any amount above usual, customary and reasonable fees as established by the plan.
incentive program: A dental benefit program that pays an increasing share of the treatment cost, provided that the covered individual utilizes the benefits of the program during each incentive period (usually a year) and receives the treatment prescribed. For example, a 70%–30% copayment program in the first year of coverage may become an 80%–20% program in the second year if the subscriber visits the dentist in the first year as stipulated in the program. Most frequently, there is a corresponding percentage reduction in the programs copayment level if the covered individual fails to visit the dentist in a given year (but never below the initial copayment level).
indigent: Those individuals whose income falls below the poverty line as defined by the federal Office of Management and Budget (OMB).
indemnity plan: A non-network dental plan that reimburses the member or dentist at a certain percentage of charges for services rendered, often after a deductible has been satisfied. Indemnity plans typically place no restrictions on which dentist a member may visit. Indemnity plans are also referred to as fee-for-service plans.
Individual Practice Association (IPA): A legal entity organized and governed by individual participating dentists for the primary purpose of collectively entering into contracts to provide dental services to enrolled populations.
insurer: The party in an insurance contract that promises to pay a benefit if a specified loss occurs. Usually an insurance company.
insured: Person covered by the program. See beneficiary.
No “J” administrative terms
No “K” administrative terms
least expensive alternative treatment (LEAT): Contractual language that allows a plan only to pay for the least expensive treatment if there is more than one way to treat a condition.
liability: An obligation to pay an amount in money, goods, or services to another party.
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. See exclusions.
managed care: Any contractual arrangement where payment or reimbursement and/or utilization are controlled by a third party. The term “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 plan benefit “ The reimbursement level determined by the administrator of a dental benefit plan for a specific dental procedure. This may vary widely by geographic region or by benefit plans within a region.
Medicaid: A federal assistance program established as Title XIX under the Social Security Act of 1965 which provides payment for medical care for certain low income individuals and families. The program is funded jointly by the state and federal governments and administered by states.
medically necessary care: The reasonable and appropriate diagnosis, treatment, and follow-up care (including supplies, appliances and devices) as determined and prescribed by qualified, appropriate health care providers in treating any condition, illness, disease, injury, or birth developmental malformations. Care is medically necessary for the purpose of: controlling or eliminating infection, pain, and disease; and restoring facial configuration or function necessary for speech, swallowing or chewing.
Medicare: A federal insurance program enacted in 1965 as Title XVIII of the Social Security Act that provides certain inpatient hospital services and physician services for all persons age 65 and older and eligible disabled individuals. The program is administered by the Centers for Medicare and Medicaid Services (CMS), previously known as the Health Care Financing Administration (HCFA).
member: An individual enrolled in a dental benefit program. See beneficiary.
Most Favored Nation Clauses: Contractual language that requires a dentist to give the beneficiaries of a dental plan the same lower fee that the dentist may have charged another patient
National Association of Insurance Commissioners (NAIC): Professional or trade association for state departments of insurance (http://www.naic.org).
National Provider Identifier (NPI): This is an identifier assigned by the federal government to all providers considered to be HIPAA covered entities. Dentists who are not covered entities may elect to obtain an NPI at their discretion, or may be enumerated if required by a participating provider agreement with a third-party payer, or applicable state law/regulation.
An NPI is unique to an individual dentist or dental entity, and has no intrinsic meaning. There are two types of NPI available to dentists and dental practices:
Type 1 Individual Provider–A health care practitioner who is a single human being. ALL dentists are eligible to apply for Type 1 NPIs, regardless of whether they are covered by HIPAA.
Type 2 Organization Provider–A health care provider that is an organization, such as a group practice or corporation. Individual dentists who are incorporated may enumerate as Type 2 providers, in addition to being enumerated as a Type 1. All incorporated dental practices and group practices are eligible for enumeration as Type 2 providers.
On paper, there is no way to distinguish a Type 1 from a Type 2 in the absence of any associated data; they are identical in format.
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 the sponsor pays the entire monthly premium for the program.
non-covered charges: See covered charges.
nonduplication of benefits: Term used to describe one of the ways the secondary carrier may calculate its portion of the payment if a patient is covered by two benefit plans. The secondary carrier calculates what it would have paid if it were the primary plan and subtracts what the other plan paid. For example, if the primary carrier paid 80 percent, and the secondary carrier normally covers 80 percent as well, the secondary carrier would not make any additional payment. If the primary carrier paid 50 percent, however, the secondary carrier would pay up to 30 percent.
nonparticipating dentist: Any dentist who does not have a contractual agreement with a dental benefit organization to render dental care to members of a dental benefit program.
NPI: See National Provider Identifier.
open enrollment: The annual period in which employees can select from a choice of benefit programs.
open panel: This type of dental benefits plan allows covered patients to receive care from any dentist and allows any dentist to participate. Any dentist may accept or refuse to treat patients enrolled in the plan. Open panel plans often are described as freedom of choice plans.
oral and maxillofacial pathologist: A dental specialist whose practice is concerned with recognition, diagnosis, investigation and management of diseases of the oral cavity, jaws, and adjacent structures.
oral and maxillofacial pathology: Oral pathology is the specialty of dentistry and discipline of pathology that deals with the nature, identification, and management of diseases affecting the oral and maxillofacial regions. It is a science that investigates the causes, processes, and effects of these diseases. The practice of oral pathology includes research and diagnosis of diseases using clinical, radiographic, microscopic, biochemical, or other examinations.
oral and maxillofacial radiologist: A dental specialist whose practice is concerned with the production and interpretation of images and data produced by all modalities of radiant energy used for the diagnosis and management of diseases, disorders and conditions of the oral and maxillofacial region.
oral and maxillofacial radiology: Oral and maxillofacial radiology is the specialty of dentistry and discipline of radiology concerned with the production and interpretation of images and data produced by all modalities of radiant energy that are used for the diagnosis and management of diseases, disorders and conditions of the oral and maxillofacial region.
oral and maxillofacial surgeon: A dental specialist whose practice is limited to the diagnosis, surgical and adjunctive treatment of diseases, injuries, deformities, defects and esthetic aspects of the oral and maxillofacial regions.
oral and maxillofacial surgery: Oral and maxillofacial surgery is the specialty of dentistry which includes the diagnosis, surgical and adjunctive treatment of diseases, injuries and defects involving both the functional and esthetic aspects of the hard and soft tissues of the oral and maxillofacial region.
oral diagnosis: The determination by a dentist of the oral health condition of an individual patient achieved through the evaluation of data gathered by means of history taking, direct examination, patient conference, and such clinical aids and tests as may be necessary in the judgment of the dentist.
oral health literacy: The degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate oral health decisions.
orthodontist: A dental specialist whose practice is limited to the interception and treatment of malocclusion and other neuromuscular and skeletal abnormalities of the teeth and their surrounding structures.
orthodontics and dentofacial orthopedics: Orthodontics and dentofacial orthopedics is the dental specialty that includes the diagnosis, prevention, interception, and correction of malocclusion, as well as neuromuscular and skeletal abnormalities of the developing or mature orofacial structures.
OSHA: Abbreviation for Occupational Safety and Health Administration. Federal agency in the US responsible for making and enforcing employee safety regulations.
overbilling: The misrepresentation of a fee as higher than actual charges; for example, when a patient is charged one fee and an insurance company is billed a higher fee to benefit the patient’s co-payment, or to increase a fee to a patient solely because the patient is covered under a dental benefits plan.
overcoding: Reporting a more complex and/or higher cost procedure than was actually performed.
participating dentist (in-network dentist): Any dentist who has a contractual agreement with a dental benefit organization to render care to eligible persons.
participating practice (in-network practice): Any dental practice or organization that has a contractual arrangement with an insurer for the provision of services under an insurance contract.
patient: An individual who has established a professional relationship with a dentist for the delivery of dental health care. For matters relating to communication of information and consent this term includes the patient’s parent, caretaker, guardian, or other individual as appropriate under state law and the circumstances of the case.
payer: A self-insured employer, insurance company, governmental agency or other party responsible for payment of health care claims of covered persons.
pediatric dentist: A dental specialist whose practice is limited to treatment of children from birth through adolescence, providing primary and comprehensive preventive and therapeutic oral health care; formerly known as a pedodontist.
pediatric dentistry: Pediatric Dentistry is an age-defined specialty that provides both primary and comprehensive preventive and therapeutic oral health care for infants and children through adolescence, including those with special health care needs.
pedodontist: See pediatric dentist.
peer review: An evaluation of the quality and conduct of an individual’s work by the individual’s professional equals (peers) in order to resolve questions or disputes regarding the quality, or conduct of the work. Peer review, when applied to dentistry, is a process, consistently structured and implemented by organized dentistry, in which a dentist’s professional equals (peers) resolve questions or disputes (regarding the quality or appropriateness of care provided by the dentist or the fairness of the fee the dentist charged in an individual case) by retrospectively evaluating the quality or appropriateness of care in relation to professional norms or criteria or evaluating the fee charged in relation to the dentist’s fee for the given complexity and level of care provided.
Peer Review Organization (PRO): An organization established by an amendment of the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA), to provide for the review of medical services furnished primarily in a hospital setting and/or in conjunction with care provided under the Medicare and Medicaid programs. In addition to their review and monitoring functions, these entities can invoke sanctions, penalties, or other corrective actions for noncompliance in organization standards.
percentile: The number in a frequency distribution below which a certain percentage of fees will fall. For example, the 90th percentile is the number that divides the distribution of fees into the lower 90% and the upper 10%, or that fee level at which 90% of dentists charge that amount or less, and 10% more.
periodontics: Periodontics is that specialty of dentistry which encompasses the prevention, diagnosis and treatment of diseases of the supporting and surrounding tissues of the teeth or their substitutes and the maintenance of the health, function and esthetics of these structures and tissues.
periodontist: A dental specialist whose practice is limited to the treatment of diseases of the supporting and surrounding tissues of the teeth.
point of service: A health plan allowing the member to choose to receive a service from a participating or non-participating provider, usually with different benefits levels associated with the use of participating providers.
post-treatment review: See audit.
predetermination: A process where a dentist submits a treatment plan to the payer before treatment begins. The payer reviews the treatment plan and notifies the dentist and patient of one or more of the following: patient’s eligibility, covered services, amounts payable, co-payment and deductibles and plan maximums.
pre-existing condition: 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 discounted fees for cost savings.
prefiling of fees: The submission of a participating dentist’s full fees for the purpose of establishing, in advance, that dentist’s full fees and the fees in a geographic area to determine benefits under a dental benefit program.
premium: The amount charged by a dental benefit organization for coverage of a level of benefits for a specified time.
prepaid group practice: See closed panel.
pretreatment estimate: See predetermination.
preventive dentistry: Aspects of dentistry concerned with promoting good oral health and function by preventing or reducing the onset and/or development of oral diseases or deformities and the occurrence of oro-facial injuries.
primary payer: The third party payer determined to have initial responsibility in a benefit determination.
prior authorization: See predetermination.
prompt payment laws: Also known as fair claims practice regulations. Enacted state by state, prompt payment laws set standards for the prompt, fair and equitable settlements of insurance claims by requiring that a set amount of interest be paid on “clean claims” that are paid beyond the established timeframe. “Clean claim” means a claim for payment of covered health care expenses that is submitted to a payer on the carrier’s standard claim form using the most current published procedural codes, with all the required fields completed with information sufficient to adjudicate the claim in accordance with the payer’s published filing requirements. These laws need to be analyzed on a case by case basis to determine whether a lawsuit has to be filed by the state department of insurance.
proof of loss: Verification of services rendered or expenses incurred by the submission of claim forms, radiographs, study models, and/or other diagnostic material. Documentary evidence required by a payer to prove a valid claim exists. It usually consists of a claim form completed by the patient’s treating dentist.
prosthodontics: Prosthodontics is the dental specialty pertaining to the diagnosis, treatment planning, rehabilitation and maintenance of the oral function, comfort, appearance and health of patients with clinical conditions associated with missing or deficient teeth and/or oral and maxillofacial tissues using biocompatible substitutes.
prosthodontist: A dental specialist whose practice is limited to the restoration of the natural teeth and/or the replacement of missing teeth with artificial substitutes.
public health dentist: A dentist whose practice is limited to the science and art of preventing and controlling dental diseases and promoting dental health through organized community efforts.
public health dentistry: Dental public health is the science and art of preventing and controlling dental diseases and promoting dental health through organized community efforts. It is that form of dental practice which serves the community as a patient rather than the individual. It is concerned with the dental health education of the public, with applied dental research, and with the administration of group dental care programs as well as the prevention and control of dental diseases on a community basis.
purchaser: Organization or entity, often employer or union, that contracts with the dental benefit organization to provide dental benefits to an enrolled population.
quadrant: One of the four equal sections into which the dental arches can be divided; begins at the midline of the arch and extends distally to the last tooth.
reimbursement: Payment made by a third party to a beneficiary or to a dentist on behalf of the beneficiary, to offset expenses incurred for a service covered by the dental benefit plan.
reinsurance: Insurance for third-party payers to spread their risk for losses (claims paid) over a specified dollar amount.
Relative Value System: Coded listing of professional services with unit values to indicate relative complexity as measured by time, skill, and overhead costs. Third-party payers typically assign a dollar value per unit to calculate provider reimbursement.
retail store dentistry: Refers to dental services offered within a retail, department or drug store operation. Typically, space is leased from the store by a separate administrative group that, in turn, subleases to a dentist or dental group providing the actual dental services. The dental operation generally maintains the same hours of operation as the store and appointments often are not necessary. Considered to be a type of practice, not a dental benefit plan model.
retrospective review: A post-treatment assessment of services on a case-by-case or aggregate basis after the services have been performed.
risk pool: A portion of provider fees or capitation payments withheld as financial reserves to cover unanticipated utilization of services in an alternative benefit plan.
schedule of allowances: See table of allowances.
schedule of benefits: A listing of dental services and the maximum benefit amounts an insurer will pay for a given service. Specificity will vary by benefit plan.
second-opinion program: An opinion about the appropriateness of a proposed treatment provided by a practitioner other than the one making the original recommendation; some benefit plans require such opinions for selected services.
self-funded plan: A benefit plan in which the plan sponsor bears the entire risk of utilization. Some plans may be partially self-funded, if the sponsor employs indemnified stop-loss insurance to protect against the risk of unanticipated higher utilization. Third party administrators may provide claims processing and other administrative services, without bearing any of the risk of utilization of the plan.
self-insurance: Setting aside of funds by an individual or organization to meet anticipated dental care expenses or its dental care claims, and accumulation of a fund to absorb fluctuations in the amount of expenses or claims. The funds set aside or accumulated are used to provide dental benefits directly instead of purchasing coverage from an insurance carrier.
service corporations: Dental benefit organizations established under not-for-profit state statutes for the purpose of providing health care coverage, e.g., Delta Dental Plans, Blue Cross and Blue Shield Plans.
statistically-based utilization review: A system that examines the distribution of treatment procedures based on claims information. In order to be reasonably reliable, the application of such claims analyses of specific dentists should include data on type of practice, dentist’s experience, socioeconomic characteristics, and geographic location.
stop-loss: A general term referring to that category of coverage that provides insurance protection (reinsurance) to an employer for a self-funded plan. summary plan description: See benefit plan summary.
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 service, but does not necessarily represent the dentist’s full fee for that service.
Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA): Legislation (Public Law 97-248) affecting health maintenance organizations and the Medicare and Medicaid programs. Provides regulations for the development of HMO risk contracting with the Medicare program and, through amendment, established new provisions for the foundation and operation of peer review organizations.
termination date: See expiration date.
third-party: The party to a dental benefit contract that may collect premiums, assume financial risk, pay claims, and/or provides other administrative services. Also known as administrative agent, carrier, insurer or underwriter.
Third-Party Administrator (TPA): Claims payer who assumes responsibility for administering health benefit 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.
Title XIX: Portion of the Social Security Act that provides for federal grants to the states for medical assistance programs, commonly known as Medicaid.
unbundling of procedures: The separating of a dental procedure into component parts with each part having a charge so that the cumulative charge of the components is greater than the total charge to patients who are not beneficiaries of a dental benefit plan for the same procedure.
upcode: Reporting a more complex and/or higher cost procedure than was actually performed. Also known as overcoding.
Usual, Customary and Reasonable Fees: See fee.
usual fee: See fee.
utilization: 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. Also, an expression of the number and types of services used by the members of a covered group over a specified period of time.
utilization management: A set of techniques used by or on behalf of purchasers of health care benefits to manage the cost of health care prior to its provision by influencing patient care decision-making through case-by-case assessments of the appropriateness of care based on accepted dental practices.
utilization review, statistically based: A system that examines the distribution of treatment procedures based on claims information and in order to be reasonably reliable, the application of such claims analyses of specific dentists should include data on type of practice, dentist’s experience, socioeconomic characteristics, and geographic location.
No “V” administrative terms
waiting period: The period between employment or enrollment in a dental program and the date when a covered person becomes eligible for a given benefit.
worker’s compensation: A benefit paid to an employee who suffers a work-related injury or illness.
X / Y / Z
No “X”, “Y”, or “Z” administrative terms
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