Descriptions of commonly used terms.

Insurance A-D

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

Claim Form: the form used to file for benefits under a dental benefit program; includes sections for the patient and the dentist to complete.

Copayment: Beneficiary's share of the dentist's fee after the benefit plan has paid.

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

Deductible: a specific amount of money that the insured must reimburse the dentist for services rendered. Usually, insurance carriers deduct this amount from the payment to the dentist and therefore, it is mandatory that this amount is collected from the patient.

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

Dependents: Generally the spose and children of a covered individual, as defined by the terms fo the dental benefit contract.

Downcoding: A practice of third-party payers in which the benefit code has been changed to a less complex and/or lower cost procedure than was reported.

 

Insurance E-L

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

Explanation of Benefits (EOB): A written statment to a beneficiary froma third-party payer after a claim has been reported, indicating the benefit/charges covered or not covered by the dental benefit plan.

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

Insured: A person covered by a program.

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

Liability: An obligation for a specific amount or action.

 

Insurance M-S

Member: An individual enrolled in a dental benefit program.

Participating provider: a dentist who accepts a particular fee schedule from an insurance company as partial payment for dental services provided.

Pre-authorization: a process by which the dentist files an estimate to the insurance carrier for planned procedures so that all parties involved can ascertain their benefit allowance, co-payments and deductible.

Schedule of Benefits: a list of procedures and/or the fees associated with these procedures and the particular amount covered by your carrier according to your specific contracted allowance.

Subscriber: the person, usually the employee, whoo represents the family unit in relation to the dental benefit program.