Glossary

A

The dollar amount a provider agrees to accept as full payment for a procedure from both the insurance company and the patient.

adjudication
The steps involved in processing a claim.

Affordable Care Act/ACA
The comprehensive Health Care Exchange (Marketplace) law, enacted in March 2010. Provisions of the ACA ensure that Americans have access to reasonably priced, comprehensive health insurance.

annual maximum
The most money a dental plan will pay for care within a benefit period. Once you reach the maximum amount, you pay any costs for the remainder of the benefit period. 

B

benefit period
The amount of time (usually 12 months) during which a plan is active. This is not always a calendar year.

benefits (in-network or out-of-network)
The amounts that Dentegra will pay for dental services under your plan or policy. In-network benefits are those covered by the plan and performed by a Dentegra provider. Out-of-network benefits are those covered by the plan but performed by a non-Dentegra provider.

C

The period of time beginning on January 1 and ending on December 31.

claim/claim form/treatment form
An itemized statement usually submitted electronically by a provider requesting payment for services from Dentegra. Sometimes a member who visits a non-Dentegra dentist may need to submit a claim. A claim form is also used to request a pre-treatment estimate.

closed panel/closed network
A dental plan that requires patients to get their care from a provider in that plan's network. 

coinsurance
A type of coverage — such as Dentegra's preferred provider organization (PPO) plans — where the member pays a percentage of the cost for a procedure. For example, if the plan's allowed amount for an office visit is $100 and the coinsurance is 20% (based on a benefit level of 80%), the member pays 20% of $100, or $20.

contracted fee
The dollar amount a contracted provider has agreed to accept as full payment for a service. 

coordination of benefits
When you are covered by more than one dental plan, the dental carriers follow a process to determine the order of payment and the amount each will pay (example: when a child is covered by both parents' plans).

copayment/copay
The fixed dollar amount a member is responsible for when receiving treatment, usually in an exclusive provider benefit (EPB) plan.

D

Dentegra provider
A provider who contracts with Dentegra. A Dentegra provider also agrees to comply with Dentegra’s administrative guidelines.

dual coverage
When a member or eligible dependent is covered by more than one dental benefits plan. Example: When you're covered by your spouse’s plan as well as your own.

E

effective date
The date a dental plan becomes active. Also, the date a member becomes eligible for benefits (not counting any waiting periods that may apply).

eligibility
Requirements that define who and when a person may qualify to enroll in a plan.

eligible dependent
Any of the dependents of a member who are eligible to enroll for benefits and who meet the conditions of eligibility as described in the plan or policy.

emergency services
Dental services that are immediately required to relieve pain, swelling or bleeding, or are required to avoid jeopardizing the patient’s health.

enrollee
See Member (may also be referred to as "patient"). 

exchange/Health Care Exchange/Marketplace
A state- or federally facilitated insurance marketplace where individuals and businesses can compare and purchase qualified health and dental plans. Referred to as Health Care Exchange (Marketplace).

exclusive provider benefit (EPB) plan
A type of plan that requires members to visit network providers to receive coverage.

Explanation of Benefits (EOB)/claims statement
The notice that members and providers receive after services have been provided and a claim processed. The EOB provides information about the fees charged, what procedures were provided, any adjustments made by the carrier and the member’s coinsurance payment.

F

fee-for-service plan
A plan where the provider is paid a specified amount per service and the member is responsible for any applicable deductible, coinsurance and amounts over the annual maximum.

H

Health and Human Services/HHS/U.S. Department of Health and Human Services/CMS
The federal agency that oversees implementation of the Affordable Care Act.

Health Care Exchange (Marketplace)
A state- or federally facilitated insurance marketplace where individuals and businesses can compare and purchase qualified health and dental plans.

I

in-network/out-of-network
Services provided in a plan either by a contracted or non-contracted provider.

• In-network providers have agreed to participate in a plan, provide treatment according to certain requirements and accept contracted fees as full payment
• Out-of-network dentists are not held to these requirements
  
  

Benefit levels differ depending on the plan and whether the member visits an in-network or out-of-network provider. Discounts under a network access plan only apply when the member visits an in-network provider.

M

maximum contract allowance
The amount on which Dentegra bases its payment (for example, a benefit level of 80% would be 80% of the contract allowance). Depending on the contract with the purchaser, the allowance may be the same as the accepted fee, a PPO fee, a table of allowance fee or some other amount.

member
A person enrolled in a dental plan. Also known as enrollee, insured or patient.  

N

network
A group of contracted providers who agree to certain fees and other contractual requirements.

non-Dentegra provider
A provider who is not in the Dentegra network, is not contractually bound to abide by Dentegra’s administrative guidelines and has not agreed to accept the Dentegra contracted fees. Also known as out-of-network provider.

O

open enrollment
The time period in which individuals and businesses may enroll in plans through their state or federal marketplace.

out-of-network
An out-of-network provider does not have a network contract with Dentegra and is not bound to follow specific fee requirements when treating patients covered under applicable plans.

P

patient pays/enrollee pays
The member's financial obligation for services, calculated when a claim is processed. The amount is the difference between the accepted fee and what Dentegra pays as shown on the claims statement.

policy
The contract of insurance issued and delivered to the member, including the application, any attached amendments and any appendices.

policy benefit level
The percentage of maximum contract allowance that Dentegra will pay after the deductible has been satisfied.

policy term
The period during which the policy is in effect.

policy year
The 12 months starting on the effective date and each subsequent 12-month period thereafter.

pre-treatment estimate
Requested by a dentist on behalf of a patient, this provides the member with an estimate of coverage and out-of-pocket costs for a proposed treatment plan.

preferred provider organization (PPO)
An open network, fee-for-service coinsurance plan that allows members to visit any licensed dentist but usually has lower costs and may have increased benefits when visiting a network dentist.

premium
The amount a member pays for coverage (PPO or EPB plan). 

primary member
The person who has the coverage or who is responsible for plan payments; also known as member. A spouse or dependent children may be covered under the primary member's plan. 

procedure code
The number given to a dental procedure as defined by the American Dental Association. These codes are standardized and used throughout the dental industry.

program allowance
The amount determined by a set percentile level of all charges for such services by providers with similar professional standing in the same geographical area.

provider
Any licensed dentist (including general dentists and specialists) who performs dental services for a member, or a hygienist, X-ray technician or other practitioner who performs dental services. A provider can also be a dental partnership, dental professional corporation or dental clinic.

S

single procedure
A dental procedure that is assigned a separate procedure code. 

specialist services
Services performed by a dental specialist, such as oral surgery, endodontics, periodontics or pediatric dentistry.

stand-alone
A stand-alone plan refers to benefits that are offered and may be purchased separately from other coverage such as medical.

submitted fee
The amount billed by a provider for a specific procedure.