Dental Insurance Terms
Need a little help getting the most out of your dental insurance? Along with this blog, check out our Dental Resources. You’ll find sections on Dental Insurance 101, Dental Insurance Terminology, Insurance Types, and loads of articles about dental and oral care topics.
The section on dental insurance terms can be a big help if you are new to dental insurance. After all, we hear about “benefits” every day, but when speaking of dental insurance, the term has a special meaning. Then there are terms like “indemnity,” “coinsurance,” and “UCR,” which you may have no idea how to define, whatever the context.
Dental Insurance lingo: A crash course
Nearly 500 terms are explained in our glossary. But you don’t have to read them all to get your bearings in the world of dental insurance.
To help you master a few of the basics, here are twenty of the most frequently used terms you’re likely to see if you’re in the market for dental insurance.
Administrator: One who manages or directs a dental benefit program on behalf of the program’s sponsor. (See Third-Party Administrator; Dental Benefit Organization.)
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. A related term, “Benefit Booklet” refers to a booklet or pamphlet which contains a general explanation of the benefits and related provisions of the dental benefit program.
Claim: A request for payment under a dental benefit plan or a statement listing services rendered, the dates of services, and itemization of costs. Includes a statement signed by the beneficiary and treating dentist that services have been rendered. The completed form serves as the basis for payment 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. 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 charged fee. Percentages vary and may apply to table of allowance plans; usual, customary, and reasonable plans; and direct reimbursement programs.
Copayment: The 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 plan.
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 Health Maintenance Organization (DHMO): Typically, the least expensive of dental plans. All dental services are provided by professional dentists who agree to provide specific treatments and services to patients at no charge (some services may require a co-payment.) DHMO plans reward participating dentists who keep patients in good health, thereby keeping plan costs low. Dentists are paid directly by the insurance company for each individual, regardless of how much or how often covered services are used.
Eligibility Date: Often referred to as “effective date,” this is the date an individual and/or dependents become eligible for benefits under a dental benefit contract.
Exclusions: Dental services not covered under a dental benefit program.
Indemnity Plans: Dental plans 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.
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.)
Maximum Benefit: The maximum dollar amount a program will pay toward the cost of dental care incurred by an individual or family in a specified period, usually a calendar year.
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.
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.
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.
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. Also known as: certificate holder, enrollee.
Usual, Customary and Reasonable (UCR): A dental benefit plan that determines benefits based on “Usual, Customary, and Reasonable” fee criteria.
Waiting Period: The period between employment or enrollment in a dental program and the date when a covered person becomes eligible for benefits.
Ready to become a dental insurance power user? Get familiar with the entire list of glossary terms.
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