employee benefit plan in which employees select their medical insurance coverage and other nontaxable fringe benefits from a list of options provided by the employer. Cafeteria plan participants may receive additional, taxable cash compensation if they select less expensive benefits.
hard deposit of mineralized material adhering to crowns and/or roots of teeth.
a relatively narrow tubular passage or channel; root canal: space inside the root portion of a tooth containing pulp tissue; mandibular canal: the passage which transmits vessels and nerves through the jaw to branches that distributes them to the teeth.
part of a fixed prosthesis that is supported at only one end.
a capitation program is one in which a dentist or dentists contract with the programs’ sponsor or administrator to provide all or most of the dental services covered under the program to subscribers in return for payment on a per-capita basis.
commonly used term for tooth decay.
see Third Party.
the monitoring and coordination of treatment rendered to patients with specific diagnoses or requiring high cost or extensive services.
see Diagnostic Cast or Study Model.
decay in tooth caused by caries; also referred to as carious lesion.
material used under a filling to replace lost tooth structure.
hard connective tissue covering the tooth root.
a radiographic head film utilized in the scientific study of the measurements of the head with relation to specific reference points.
1) The person, usually the employee, who represents the family unit covered by the dental benefit program; other family members are referred to as "dependents." 2) Generally refers to a subscriber of a traditional indemnity program. 3) In reference to the program for dependents of active-duty military personnel, the certificate holder is called the sponsor. (see Subscriber.)
1) A request for payment under a dental benefit plan. 2) 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.
the form used to file for benefits under a dental benefit program; includes sections for the patient, and the dentist to complete.
person who files a claim for benefits. May be the patient or the certificate holder.
Claims Payment Fraud
the intentional manipulation or alteration of facts submitted by a treating dentist resulting in a lower payment to the beneficiary and/or the treating dentist than would have been paid if the manipulation had not occurred.
Claims Reporting Fraud
the intentional misrepresentation of material facts concerning treatment provided and/or charges made, in that this misrepresentation would cause a higher payment.
congenital deformity resulting in lack of fusion of the soft and/or hard palate, either partial or complete.
the clamping and pressing of the jaws and teeth together in centric occlusion, frequently associated with psychological stress or physical effort.
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. As a result of the dentist reimbursement methods characteristic of a closed panel plan, only a small percentage of practicing dentists in a given geographical area are typically contracted by the plan to provide dental services.
the re-approximation of segments of a fractured bone without open surgery.
a provision of a dental benefit program by which the beneficiary shares in the cost of covered services, generally on a percentage basis. The percentage of a covered dental expense that a beneficiary must pay (after the deductible is paid). 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.
a dental restorative material made up of disparate or separate parts (e.g. resin and quartz particles).
break in bone which is exposed to external contamination.
Comprehensive Oral Evaluation
comprehensive oral evaluation - new or established patient: Typically used by a general dentist and/or a specialist when evaluating a patient comprehensively. This applies to new patients; established patients who have had a significant change in health conditions or other unusual circumstances, by report, or established patients who have been absent from active treatment for three or more years. It is a thorough evaluation and recording of the extraoral and intraoral hard and soft tissues. It may require interpretation of information acquired through additional diagnostic procedures. This would include the evaluation and recording of the patient’s dental and medical history and a general health assessment. It may typically include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, occlusal relationships, periodontal conditions (including periodontal charting), hard and soft tissue anomalies, oral cancer screening, etc.
Consolidated Omnibus Budget Reconciliation Act (COBRA)
legislation relative to mandated benefits for all types of employee benefit plans. The most significant aspects within this context are the requirements for continued coverage for employees and/or their dependents for 18 months who would other-wise lose coverage (30 months for dependents in the event of the employee’s death).
Contacts are corrective or cosmetic lenses that are placed directly on the wearer’s eyes. The clear, plastic discs float on the wet film on the surface of the eyes. Various types include hard and soft contact lenses. Soft contacts include single use, daily wear, and extended wear varieties.
a legally enforceable agreement between two or more individuals or entities which confers rights and duties on the parties. Common types of contracts include: 1) contracts between a dental benefit organization and an individual dentist to provide dental treatment to members of an alternative benefit plan. These contracts define the dentist’s duties both to beneficiaries of the dental benefit plan and the dental benefit organization, and usually define the manner in which the dentist will be reimbursed; and 2) contracts between a dental benefit organization and a group plan sponsor. These contracts typically describe the benefits of the group plan and the rates to be charged for those benefits.
a practitioner that contractually agrees to provide services under special terms, conditions and financial reimbursement arrangements.
Contract Fee Schedule Plan
a dental benefit plan in which participating dentists agree to accept a list of specific fees as the total fees for dental treatment provided.
dental practice in which an employer or third-party administrator contracts directly with a dentist or group of dentists to provide dental services for beneficiaries of a plan. (see Closed Panel).
the period of time, usually 12 months, for which a contract is written.
a dental benefit program in which the enrollee shares in the monthly premium of the program with the program sponsor (usually the employer). Generally done through payroll deduction.
Coordination of Benefits (COB)
a method of integrating benefits payable for the same patient under more than one plan. Benefits from all sources should not exceed 100% of the total charges.
beneficiary’s share of the dentist’s fee after the benefit plan has paid.
a thin covering of the coronal portion of the tooth usually without anatomic conformity. It can be used as a definitive restoration or as part of a transfer procedure.
refers to the clinical crown of a tooth.
features of a dental benefit program or of the administration of the program designed to reduce or eliminate certain charges to the plan.
the share of health expenses that a beneficiary must pay, including the deductibles, copayments, coinsurance, and charges over the amount reimbursed by the dental benefit plan.
benefits available to an individual covered under a dental benefit plan.
charges for services rendered or supplies furnished by a dentist that qualify as covered services and are paid for in whole or in part by the dental benefit program. May be subject to deductibles, copayments, coinsurance, annual or lifetime maximums, as specified by the terms of the contract.
an individual who is eligible for benefits under a dental benefit program.
services for which payment is provided under the terms of the dental benefit contract.
anatomical crown - that portion of tooth normally covered by, and including, enamel; abutment crown - artificial crown serving for the retention or support of a dental prosthesis; artificial crown - restoration covering or replacing the major part, or the whole of the clinical crown of a tooth; clinical crown - that portion of a tooth not covered by supporting tissues.
a surgical procedure exposing more tooth for restorative purposes by apically positioning the gingival margin and/or removing supporting bone.
scraping and cleaning the walls of a cavity or gingival pocket
Current Dental Terminology (CDT)
a listing of descriptive terms and identifying codes developed by the American Dental Association (ADA) for reporting dental services and procedures to dental benefit plans.
Current Procedural Terminology (CPT)
a listing of descriptive terms and identifying codes developed by the American Medical Association (AMA) for reporting practitioner services and procedures to medical plans and medicare.
pointed or rounded eminence on or near the masticating surface of a tooth.
the fee level determined by the administrator of a dental benefit plan from actual submitted fees for a specific dental procedure to establish the maximum benefit payable under a given plan for that specific procedure. (see also Usual Fee and Reasonable Fee.)
pathological cavity, usually lined with epithelium, containing fluid or soft matter; odontogenic cyst - cyst derived from the epithelium of odontogenic tissue (developmental, primordial); periapical cyst - cyst at the apex of a tooth with a non-vital pulp.