We know that consumers want to be as informed as possible when choosing a dental plan. Below you will find a listing of common terms dealing with dental benefits and dental plans to help you be able to make the best possible choice in regards to dental care.

Allowable charges

The maximum dollar amount on which a benefit payment is based for each dental procedure.

Beneficiary

A person who receives benefits under a dental benefit/plan/insurance contract.

Benefit

The amount payable by a third party toward the cost of various covered dental services and/or procedures covered by the plan.

Benefit booklet

A booklet provided to the subscriber which contains a general explanation of the benefits and provisions of the dental benefit program.

Certificate holder

The person, usually the employee or responsible party, who represents the family unit covered by the dental benefit program; other family members covered 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 services are provided by dentists who have signed an agreement with the benefit plan to provide treatment to eligible patients.

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 where participating dentists agree to accept a list of specific fees as the total fees for dental treatment(s) 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 for a service or procedure under the terms of the dental benefit contract.

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, co-insurance, 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 dental benefit provider.

Dental insurance

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

Dependents

Generally spouse and children of covered individual, as defined by terms of the dental benefit contract.

Eligibility date

The date an individual and/or dependents become eligible for benefits under a dental benefit contract. Also referred to as effective date.

Enrollee

Individual covered by a benefit plan.

Exclusions

Dental services that are not covered under a dental benefit program.

Expiration date

Refers to the date on which the dental benefit contract expires or the date an individual ceases to be eligible for benefits.

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 and procedures.

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. 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.

Indemnity plan

A dental plan/program where a third party payer provides payment of an amount for specific services, regardless of the actual charges made by the provider. 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.

Liability

An obligation for a specified amount or action.

Limitations

Restrictive conditions stated in a dental benefit contract, such as length of time covered or waiting periods, which affect the coverage of an individual or group. The contract may also exclude certain benefits or services, or it may limit the extent or conditions under which certain services are provided.

Managed care

Refers to a cost containment system that directs the utilization of health benefits by restricting the type, level and frequency of treatment, limiting the access to care and 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 or procedure as specified in the program’s contract provisions.

Maximum benefit

The maximum dollar amount a program will pay toward the cost of dental care incurred by an individual, group or family in a specific period.

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 or procedures.

Member

An individual enrolled in a dental benefit program.

Necessary treatment

A necessary dental procedure or service as determined by a dentist, to either establish or maintain a patient’s oral health.

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

May apply if a subscriber is eligible for benefits for a procedure or service 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.

Nonparticipating dentist

Any dentist who does not have a contractual agreement with a dental benefit organization to render dental care/services to members of a specific dental benefit program.

Open enrollment

The annual period in which employees can select from a choice of benefit programs.

Participating dentist

Any dentist who has a contractual agreement with a dental benefit organization to render care/services to eligible persons.

Preauthorization

Statement by a third party payer indicating that a proposed treatment or procedure will be covered under the terms of the benefit contract.

Precertification

Confirmation by a third party payer of a patient’s eligibility for coverage for a procedure or service under a dental benefit program.

Predetermination

An administrative procedure that may require the dentist to submit a treatment plan to the third party payer before treatment is begun.

Pre-existing conditions

An 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 using discount fees for cost savings.

Premium

The amount charged by a dental benefit organization for coverage of a certain 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 the receipt of services.

Prevailing fee

Term used by some dental benefit organizations to refer to the fee most commonly charged for a dental service or procedure 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 an employer or union, that contracts with the dental benefit organization to provide dental benefits to a specified enrolled population.

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 dental care rendered.

Reasonable and customary 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, 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 pr procedure that is covered by the contractual arrangement.

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 always represent the dentist’s full fee for that service or procedure.

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 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 a third party payer.

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 always represent the dentist’s full fee for that service or procedure.

Termination date

Refers to the date on which the dental benefit contract expires or the date that and individual ceases to be eligible for benefits.

Third party

The party to a dental benefit contract that may collect premiums, assume financial risk, pay claims, and provide other administrative services.

Third party administrator (TPA)

Claims payer who assumes responsibility for administering health benefit plans without assuming any financial risk.

Third party payer

An organization other than the patient (first party) or health care provider (second party) involved in the financing of personal health or dental services.

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 or procedure.

Utilization

Refers to the extent to which the members of a covered group use a program over a stated period of time or an expression of the number and types of services used by the members of a covered group over a specified period of time.

Waiting period

The period between employment or enrollment in a dental program and the date when a covered person becomes eligible for dental benefits.