Bad Faith Insurance Practices
the failure to deal with a beneficiary of a dental benefit plan fairly and in good faith; an activity which impairs the right of the beneficiary to receive the appropriate benefits of a dental benefit plan or to receive them in a timely manner. Some examples of 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 benefits; and unreasonably and purposely delaying and/or withholding payment of a claim.
billing a patient for the difference between the dentist’s actual charge and the amount reimbursed under the patient’s dental benefit plan.
a person who receives benefits under a dental benefit contract. (see also Covered Person, Insured, Member, Subscriber.)
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 booklet or pamphlet provided to the subscriber which 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 required by ERISA to be distributed to the employees.
the mild character of an illness or the non-malignant character of a neoplasm.
a premolar tooth; a tooth with two cusps.
occurring on, or pertaining to, both right and left sides.
process of removing tissue for histologic evaluation.
coordination of benefits regulation stipulating that the primary payer of benefits for dependent children is determined by the parents date of birth. Regardless of which parent is older, the dental benefit program of the parent whose date of birth falls first in a calendar year is considered primary. (May not apply to “self-funded” programs).
interproximal view radiograph of the coronal portion of the tooth.
process by which two or more components are made integral by mechanical and/or chemical adhesion at their interface.
see Fixed Partial Denture and/or Removable Partial Denture.
the parafunctional grinding of the teeth.
pertaining to or around the cheek (as in the buccal surface of a posterior tooth).
Bundling of Procedures
the systematic combining of distinct dental procedures by third-party payers that results in a reduced benefit for the patient/beneficiary.
a narrative description used to report a service that does not have a procedure code or is specified in a code as "by report"; may be requested by a third-party payer to provide additional information for claims processing.