Acute or chronic localized inflammation with a collection of pus, associated with tissue destruction and, frequently, swelling; usually secondary to infection.
A tooth or implant used to support a prosthesis.
see "crown"; "retainer."
addition of a test specimen, previously collected by a health care provider, to a laboratory specimen collection; recording of essential specimen identification data in a laboratory-maintained file in chronological order of laboratory specimen acquisition; assignment to the specimen of an identification code.
use of an acidic chemical substance to prepare the tooth enamel and or dentin surface to provide retention for bonding.
any substance that joins or creates close adherence of two or more surfaces.
overhead expenses incurred in the operation of a dental benefit program, exclusive of costs of dental services provided.
Administrative Services Only (ASO)
an arrangement under which a third party, for a fee, processes claims and handles paperwork for a self-funded group. This frequently includes all insurance company services (actuarial services, underwriting, benefit description, etc.) except assumption of risk.
one who manages or directs a dental benefit program on behalf of the program's sponsor. (See Third-Party Administrator; Dental Benefit Organization.)
the permanent teeth of adulthood that either replace or are added to the primary dentition.
a statistical condition within a group when there is a greater demand for dental services and/or more services necessary than the average expected for that group.
belonging to the same species, but genetically different. See Graft.
refers to synthetic material often used for tissue augmentation.
the maximum dollar amount on which benefit payment is based for each dental procedure.
a provision in a dental plan contract that allows the third-party payer to determine the benefit based on an alternative procedure that is generally less expensive than the one provided or proposed.
Alternative Benefit Plan
a plan, other than a traditional (fee-for-service, freedom-of-choice) indemnity or service corporation plan, for reimbursing a participating dentist for providing treatment to an enrolled patient population.
Alternative Delivery System
an arrangement for the provision of dental services in other than the traditional way (e.g., licensed dentist providing treatment in a fee-for-service dental office).
referring to the bone to which a tooth is attached
surgical procedure for recontouring alveolar structures, sometimes in preparation for prosthesis.
an alloy used in direct dental restorations.
loss of pain sensations without loss of consciousness.
subordinate or auxiliary to something or someone else; supplementary
a patient's level of consciousness is determined by the provider and not the route of administration of anesthesia. State dental boards regulate the use of anesthesia techniques. local anesthesia – The elimination of sensation, especially pain, in one part of the body by the topical application or regional injection of a drug. regional anesthesia – A term used for local anesthesia; see Local Anesthesia. conscious sedation - a minimally depressed level of consciousness that retains the patient's ability to independently and continuously maintain an airway and respond appropriately to physical stimulation or verbal command and that is produced by a pharmacological or non-pharmacological method or a combination thereof. deep sedation - an induced state of depressed consciousness accompanied by partial loss of protective reflexes, including the inability to continually maintain an airway and respond purposefully to physical stimulation or verbal command, and is produced by a pharmacologic or non-pharmacological method or a combination thereof. general anesthesia - an induced state of unconsciousness, accompanied by a partial or complete loss of protective reflexes, including the inability to continually maintain an airway independently and respond purposefully to physical stimulation or verbal command, produced by a pharmacologic or non-pharmacologic method or a combination thereof. enteral - any technique of administration in which the agent is absorbed through the gastrointestinal tract or oral mucosa (e. g., oral, rectal, sublingual). parenteral - a technique of administration in which the drug bypasses the gastrointestinal tract (e. g., intramuscular [IM], intravenous [IV], intranasal [IN], submucosal [SM], subcutaneous [SC], intraocular [IO].)
deviation from the normal anatomic growth, development or function; an abnormality.
designation for standards recognized by the American National Standards Institute/American Dental Association/International Standards Organization.
refers to the teeth and tissues located towards the front of the mouth; maxillary and mandibular incisors and canines. The designation of permanent anterior teeth in the Universal tooth numbering system include teeth 6 through 11 (maxillary), and 22 through 27 (mandibular); primary teeth in the Universal tooth numbering system are designated C through H (maxillary), and M through R (mandibular).
Any Willing Provider
legislation that requires managed care organizations (MCOs), such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs) to contract with any providers, from physicians and hospitals to pharmacists and chiropractors, who are willing to meet the terms of the contract.
the tip or end of the root end of the tooth.
the process of induced root development.
amputation of the apex of a tooth
a request to a dental plan to review a decision that denied or limited the treatment or proposed treatment to the beneficiary of the plan; usually made by the attending dentist on behalf of the plan beneficiary.
the curved composite structure of the natural dentition and the residual ridge, or the remains thereof, after the loss of some or all of the natural teeth.
Areas of oral cavity
a two digit numeric system used to report regions of the oral cavity to third-party payers.
a diagnostic X-ray technique used to view bone structures following injection of a contrast medium into a joint.
Assignment of Benefits
a procedure whereby a beneficiary/patient authorizes the administrator of the program to forward payment for a covered procedure directly to the treating dentist.
Attending dentist statement
also known as the ADA Dental Claim Form. A form used to report dental procedures to a third-party payer. The claim form was developed by the American Dental Association.
an examination of records or accounts to check their accuracy. A post-treatment record review or clinical examination to verify information reported on claims.
separation of tooth from its socket due to trauma (evulsion).
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.
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.
removal of subgingival and/or supragingival plaque and calculus which obstructs the ability to perform an evaluation; removal of contused and devitalized tissue; from a wound surface.
the lay term for carious lesions in a tooth; decomposition of tooth structure.
having the property of falling off or shedding; a name used for the primary teeth.
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 Benefit 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, coinsurance, 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 sponsor.
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.
a plan that financially assists in the expense of treatment and care of dental disease and accidents to teeth.
Dental Prepaid plan is commonly referred to as a Dental HMO (DHMO). Dental Health Maintenance Organization (DHMO) is an organized system of dental health care that provides comprehensive and affordable care to you through a network of highly qualified dentists. There are no waiting periods, calendar year maximums or deductibles and no claim forms. With these plans, you are responsible for the copayment for each service.
a method of financing the cost of dental services prior to their receipt.
scaling and polishing procedure performed to remove coronal plaque, calculus, and stains.
Dental Service Corporation
a legally constituted, not-for-profit organization that negotiates and administers contracts for dental care. Delta Dental Plans and Blue Cross/Blue Shield Plans are such plans.
that part of the tooth that is beneath enamel and cementum.
the teeth in the dental arch; permanent dentition - refers to the permanent teeth in the dental arch; deciduous dentition -- refers to the deciduous or primary teeth in the dental arch.
an artificial substitute for natural teeth and adjacent tissues.
that part of a denture that makes contact with soft tissue and retains the artificial teeth.
generally spouse and children of covered individual, as defined by terms of the dental benefit contract.
Detailed and Extensive
detailed and extensive oral evaluation - problem- focused, by report: A detailed and extensive problem-focused evaluation entails extensive diagnostic and cognitive modalities based on the findings of a comprehensive oral evaluation. Integration of more extensive diagnostic modalities to develop a treatment plan for a specific problem is required. The condition requiring this type of evaluation should be described and documented. Examples of conditions requiring this type of evaluation may include dentofacial anomalies, complicated perio-prosthetic conditions, complex temporomandibular dysfunction, facial pain or unknown origin, conditions requiring multi-disciplinary consultations, etc.
plaster or stone model of teeth and adjoining tissues; also referred to as study model.
a space, such as one between two adjacent teeth in the same dental arch.
a process whereby the dentist bills a patient directly for his/her fees.
Direct Pulp Cap
procedure in which the exposed pulp is covered with a dressing or cement with the aim of maintaining pulp vitality.
a self-funded program in which the individual is reimbursed based on a percentage of dollars spent for dental care provided, and which allows beneficiaries to seek treatment from the dentist of their choice.
a restoration fabricated inside the mouth.
excision of the intra-articular disc of a joint.
a partial evulsion of a tooth-may be mesial, distal, facial, lingual or incisal.
toward the back of the dental arch (or away from the midline).
a practice of third-party payers in which the benefit code has been changed to a less complex and/or lower cost procedure than was reported.
DRGs (Diagnosis-Related Groups)
a system of classifying hospital patients on the basis of diagnosis, consisting of distinct groupings. A DRG assignment to a case is based on the patient’s 1) principal diagnosis; 2) treatment procedures performed; 3) age; 4) gender; 5) discharge status.
localized inflammation of the tooth socket following extraction due to infection or loss of blood clot; osteitis.
Dual Choice Program
a benefit package from which an eligible individual can choose to enroll in either an alternative dental benefit program or a traditional dental benefit program.
the date an individual and/or dependents become eligible for benefits under a dental benefit contract. Often referred to as effective date.
Employment Retirement Income Security Act (ERISA)
a federal act, passed in 1974, that established new standards and reporting/disclosure requirements for employer-funded pension and health benefit programs. To date, self-funded health benefit plans operating under ERISA have been held to be exempt from state insurance laws. This exemption is currently under review.
hard calcified tissue covering dentin of the crown of tooth.
a dental specialist who limits his/her practice to treating disease and injuries of the pulp and associated periradicular conditions.
individual covered by a benefit plan. (see Beneficiary).
reshaping of the occlusal surfaces of teeth to create harmonious contact relationships between the upper and lower teeth; also known as occlusal adjustment.
patient who has a record of recent care.
see "periodic oral evaluation", "limited oral evaluation", "comprehensive oral evaluation", or "detailed and extensive oral evaluation".
complete separation of the tooth from its socket due to trauma (avulsion).
surgical removal of bone or tissue.
dental services not covered under a dental benefit program.
Exclusive Provider Organization (EPO)
a dental benefit plan that provides benefits only if care is rendered by institutional and professional providers with whom the plan contracts (with some exceptions for emergency and out-of-area services).
overgrowth of bone (see Torus).
1) The date on which the dental benefit contract expires. 2) The date and individual ceases to be eligible for benefits.
Explanation of Benefits
a written statement to a beneficiary, from a third-party payer, after a claim has been reported, indicating the benefit/charges covered or not covered by the dental benefit plan.
Extension of Benefits
extension of eligibility for benefits for covered services, usually designed to ensure completion of treatment commenced prior to the expiration date. Duration is generally expressed in terms of days.
outside the crown of a tooth.
outside the oral cavity.
a material usually resulting from inflammation or necrosis that contains fluid, cells, and/or other debris.
An eye examination includes several tests that are performed by a doctor who specializes in eye health. During an exam, vision and the ability to focus are checked and other factors related to eye health are evaluated. Because many eye diseases show no symptoms, it is important to have regular, comprehensive eye exams.
the surface of a tooth directed toward the face (including the buccal and labial surfaces) and opposite the lingual surface. Facial surface equals buccal surface in the posterior or the labial in the anterior.
a deductible that is satisfied by combined expenses of all covered family members. For example, a program with $25 deductible may limit its application to a maximum of three deductibles, or $75 for the family, regardless of the number of family members. (see Deductible.)
a list of the charges established or agreed to by a dentist for specific dental services.
a method of paying practitioners on a service-by-service rather than a salaried or capitated basis.
a lay term used for the restoring of lost tooth structure by using materials such as metal, alloy, plastic or porcelain.
Fixed Partial Denture
a prosthetic replacement of one or more missing teeth cemented or attached to the abutment teeth or implant abutments adjacent to the space.
a benefit program in which an employee has a choice of credits or dollars for distribution among various benefit options, e.g., health and disability insurance, dental benefits, child care, or pension benefits. (see Cafeteria Plans; Flexible Spending Account).
Flexible Spending Account
employee reimbursement account primarily funded with employee designated salary reductions. Funds are reimbursed to employee for health care (medical and/or dental), dependent care, and/or legal expenses, and are considered a nontaxable benefit.
natural opening into or through bone.
the breaking of a part, especially of a bony structure; breaking of a tooth.
Eyeglasses or spectacles come in a variety of types, but all are made of two main parts: the lenses, and the frames that hold them in place. Frames and lenses can be made from various materials to serve a range of purposes. These include improving vision, protecting against physical objects or UV light, and making a fashion statement.
Refers to a system for marketing a dental practice, usually under a trade name, where permitted by state laws. In return for a financial investment or other consideration, participating dentists may also receive the benefits of media advertising, a national referral system, and financial and management consultation.
Freedom of Choice
a provision in a dental benefit program that permits the insured to choose any licensed dentist to provide his or her dental care and receive full benefits under the program.
muscle fibers covered by a mucous membrane that attaches the cheek, lips and or tongue to associated dental mucosa.
the anatomic area of a multirooted tooth where the roots diverge.
Gate Keeper System
a managed care concept used by some alternative benefit plans, in which enrollees select a primary care dentist, usually a general practitioner or pediatric dentist, who is responsible for providing nonspecialty care and managing referrals, as appropriate, for specialty and ancillary care.
soft tissues overlying the crowns of unerupted teeth and encircling the necks of those that have erupted.
the excision or removal of gingiva.
inflammation of gingival tissue without loss of connective tissue.
surgical procedure to reshape gingiva.
glass polyalkenoate cement: material in which the solid powdered phase is a fluoride-containing aluminosilicate glass powder. The material is translucent and can be used as a restoration, a liner and a luting agent.
a piece of tissue or alloplastic material placed in contact with tissue to repair a defect or supplement a deficiency; allogenic graft - having cell types that are antigenetically distinct from patient’s cell type (usually freeze dried and/or irradiated); autogenous graft - taken from one part of a patient’s body and transferred to another; homologous graft - a graft transplanted from a donor of the same species.
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. An organized system of health care delivery that provides comprehensive care to enrollees through designated providers. Enrollees are generally assessed a monthly payment for heath care services and may be required to remain in the program for a specified amount of time.
surgical separation of a multi-rooted tooth.
made up of tissue not normal to the part.
the study of disease processes at the cellular level.
Hold Harmless Clause
a contract provision in which one party to the contract promises to be responsible for liability incurred by the other party. Hold harmless clauses frequently appear in the following contexts: 1) Contracts between dental benefit organizations and an individual dentist often contain a promise by the dentist to reimburse the dental benefit organization for any liability the organization incurs because of dental treatment provided to beneficiaries of the organization’s dental benefit plan. This may include a promise to pay the dental benefit organization’s attorney fees and related costs; and 2) Contracts between dental benefit organizations and a group plan sponsor may include a promise by the dental benefit organization to assume responsibility for disputes between a beneficiary of the group plan and an individual dentist when the dentist’s charge exceeds the amount the organization pays for the service on behalf of the beneficiary. If the dentist takes action against the patient to recover the difference between the amount billed by the dentist and the amount paid by the organization, the dental benefit organization will take over the defense of the claim and will pay any judgments and court costs.
this would include, but is not limited to, CAT scans, MRIs, photographs, radiographs, etc.
prosthesis constructed for placement immediately after removal of remaining natural teeth.
an unerupted or partially erupted tooth that is positioned against another tooth, bone, or soft tissue so that complete eruption is unlikely.
material inserted or grafted into tissue; dental implant - device specially designed to be placed surgically within or on the mandibular or maxillary bone as a means of providing for dental replacement; endosteal (endosseous); eposteal (subperiosteal); transosteal (transosseous).
placement of an artificial or natural tooth into an alveolus.
a dental benefit program that pays an increasing share of the treatment cost, provided that the covered individual utilizes the benefits of the program during each incentive period (usually a year) and receives the treatment prescribed. For example, a 70%-30% copayment program in the first year of coverage may become an 80%-20% program in the second year if the subscriber visits the dentist in the first year as stipulated in the program. Most frequently, there is a corresponding percentage reduction in the programs copayment level if the covered individual fails to visit the dentist in a given year (but never below the initial copayment level).
pertaining to the biting edges of the incisor and cuspid teeth.
one of the angles formed by the junction of the incisal and the mesial or distal surfaces of an anterior tooth; called the mesioincisal and distoincisal angle respectfully.
see Table of Allowances.
a dental plan 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.
Indirect Pulp Cap
procedure in which the nearly exposed pulp is covered with a protective dressing to protect the pulp from additional injury and to promote healing and repair via formation of secondary dentin.
a restoration fabricated outside the mouth.
Individual Practice Association (IPA)
a legal entity organized and operated on behalf of individual participating dentists for the primary purpose of collectively entering into contracts to provide dental services to enrolled populations. Dentists may practice in their own offices and may provide care to patients not covered by the contract as well as IPA patients.
an indirect intracoronal restoration; a dental restoration made outside of the oral cavity to correspond to the form of the prepared cavity, which is then luted into the tooth.
Person covered by the program. (see Beneficiary.)
an organization that bears the financial risk for the cost of defined categories or services for a defined group of beneficiaries. (See Third Party.)
the intentional removal, radicular repair and replacement of a tooth into its alveolus.
International Classification of Diseases, (ICD)
diagnostic codes designed for the classification of morbidity and mortality information for statistical purposes, and for the indexing of hospital records by disease and operations, for data storage and retrieval.
between the adjoining surfaces of adjacent teeth in the same arch.
referring to “within” the crown of a tooth.
inside the mouth.
conscious sedation see anesthesia.
a common name for either the maxilla or the mandible.
a protein present in all cuticular structures of the body, such as hair, epidermis and horns.
the oral surface of the gingiva extending from the mucogingival junction to the gingival margin. In gingival health, the coronal portion of the sulcular epithelium may also be keratinized.
pertaining to or around the lip.
Least Expensive Alternative Treatment (LEAT)
a limitation in a dental benefit plan that will only allow benefits for the least expensive treatment. Also referred to as Least Expensive Professionally Acceptable Alternative Treatment (LEPAAT).
an injury or wound; area of diseased tissue.
an obligation for a specified amount or action.
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.)
Limited Oral Evaluation
limited oral evaluation - problem focused: An evaluation limited to a specific oral health problem or complaint. This may require interpretation of information acquired through additional diagnostic procedures. Definitive procedures may be required on the same date as the evaluation. Typically, patients receiving this type of evaluation present with a specific problem and/or dental emergencies, trauma, acute infection, etc.
an angle formed by the junction of two planes; used to designate the junction of two surfaces of a tooth, or of two walls of a tooth cavity preparation.
pertaining to or around the tongue; surface of the tooth directed toward the tongue; opposite of facial.
a site or location.
therapy for preserving the state of health of the periodontium.
pertaining to the cheek bone; see Zygomatic Bone.
having the properties of dysplasia, invasion, and metastasis.
improper alignment of biting or chewing surfaces of upper and lower teeth.
refers to a cost containment system that directs the utilization of health benefits by: a. restricting the type, level and frequency of treatment; b. limiting the access to care; and c. controlling the level of reimbursement for services.
fixed partial denture featuring conservative retainers which are resin bonded to abutments; see Code D6545.
the upper jaw.
the maximum dollar amount a dental program will pay toward the cost of a dental service as specified in the program’s contract provisions, e.g., UCR, Table of Allowances
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.
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.
a federal assistance program established as Title XIX under the Social Security Act of 1965 which provides payment for medical care for certain low income individuals and families. The program is funded jointly by the state and federal governments and administered by states.
Medically Necessary Care
the reasonable and appropriate diagnosis, treatment, and follow-up care (including supplies, appliances and devices) as determined and prescribed by qualified, appropriate health care providers in treating any condition, illness, disease, injury, or birth developmental malformations. Care is medically necessary for the purpose of: controlling or eliminating infection, pain, and disease; and restoring facial configuration or function necessary for speech, swallowing or chewing.
toward the midline of the dental arch; opposite of distal.
Metals, Classification of
the noble metal classification system has been adopted as a more precise method of reporting various alloys used in dentistry. The alloys are defined on the basis of the percentage of noble metal content: high noble - Gold (Au), Palladium (Pd), and/or Platinum (Pt) > 60% (with at least 40% Au); noble - Gold (Au), Palladium (Pd), and/or Platinum (Pt)> 25%; and predominantly base - Gold (Au), Palladium (Pd), and/or Platinum (Pt) < 25%.
teeth posterior to the premolars (bicuspids) on either side of the jaw; grinding teeth, having large crowns and broad chewing surfaces.
a positive reproduction of a body part formed on a cast from a negative impression.
lining of the oral cavity as well as other canals and cavities of the body; also called “mucosa.”
a graft from donor other than patient.
a disc or plate which closes an opening; a prosthesis that closes an opening in the palate.
an intraoral radiograph made with the film being held between the occluded teeth.
any contact between biting or chewing surfaces of maxillary (upper) and mandibular (lower) teeth.
adjustment of tooth length, size, and/or shape; includes removal of enamel projections.
an indirect restoration made outside the oral cavity that overlays a cusp or cusps of the tooth, which is then luted to the tooth.
re-approximation of fractured bony segments accomplished through cutting the adjacent soft tissues and bone to allow direct access.
removal of the operculum.
the flap of tissue over an unerupted or partially erupted tooth.
pertaining to the mouth.
Oral and Maxillofacial Surgeon
a dental specialist whose practice is limited to the diagnosis, surgical and adjunctive treatment of diseases, injuries, deformities, defects and esthetic aspects of the oral and maxillofacial regions.
the specialty of dentistry and pathology concerned with recognition, diagnosis, investigation and management of diseases of the oral cavity, jaws, and adjacent structures.
a dental specialist whose practice is limited to the interception and treatment of malocclusion of the teeth and their surrounding structures.
functional relationship of maxilla and mandible.
surgical procedure that modifies the configuration of bone.
surgical cutting of bone.
a removable prosthetic device that overlies and may be supported by retained tooth roots or implants.
the hard and soft tissues forming the roof of the mouth that separates the oral and nasal cavities.
action that relieves pain but is not curative.
an extraoral radiograph on which the maxilla and mandible are depicted on a single film.
other than normal function or use
usually refers to a prosthetic device that replaces missing teeth; (see fixed partial denture or removable partial denture).
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.
a dental specialist whose practice is limited to treatment of children from birth through adolescence; formerly known as a pedodontist.
see Pediatric Dentist.
1) A retrospective consideration or an examination by one or more individuals of equal standing or rank. 2) A process established to provide for review by licensed dentists of: the care provided by a dentist for a single patient; disputes regarding fees; cases submitted by carriers, initiated by patients or dentists; quality of care and appropriateness of treatment.
Peer Review Organization (PRO)
an organization established by an amendment of the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA), to provide for the review of medical services furnished primarily in a hospital setting and/or in conjunction with care provided under the Medicare and Medicaid programs. In addition to their review and monitoring functions, these entities can invoke sanctions, penalties, or other corrective actions for noncompliance in organization standards.
the number in a frequency distribution below which a certain percentage of fees will fall. For example, the 90th percentile is the number that divides the distribution of fees into the lower 90% and the upper 10%, or that fee level at which 90% of dentists charge that amount or less, and 10% charge more.
the area surrounding the end of the tooth root.
a radiograph made by the intraoral placement of film for disclosing the apices of the teeth.
around the crown of a tooth.
Periodic Oral Evaluation
An evaluation performed on a patient of record to determine any changes in the patient’s dental and medical health status since a previous comprehensive or periodic evaluation. This includes periodontal screening and may require interpretation of information acquired through additional diagnostic procedures.
pertaining to the supporting and surrounding tissues of the teeth.
inflammatory process of the gingival tissues and/or periodontal membrane of the teeth, resulting in an abnormally deep gingival sulcus, possibly producing periodontal pockets and loss of supporting alveolar bone.
pathologically deepened gingival sulcus; a feature of periodontal disease.
a dental specialist whose practice is limited to the treatment of diseases of the supporting and surrounding tissues of the teeth.
inflammation and loss of the connective tissue of the supporting or surrounding structure of teeth with loss of attachment.
surrounding a portion of the root of the tooth.
a soft sticky substance that accumulates on teeth composed largely of bacteria and bacterial derivatives.
Point of Service (POS)
an option that a health insurance issuer offers to enrollees health insurance coverage which provides for coverage of services only if such services are furnished through health professionals and providers who are members of a network of health professionals and providers who have entered into a contract with the issuer to provide such services, the issuer shall also offer to such enrollees (at the time of enrollment) the option of health insurance coverage which provides for coverage of such services which are not furnished through health professionals and providers who are members of such a network.
the term used for an artificial tooth on a fixed partial denture (bridge).
an elongated projection fitted and cemented within the prepared root canal, serving to strengthen and retain restorative material and/or a crown restoration.
refers to teeth and tissues towards the back of the mouth (distal to the canines) - maxillary and mandibular premolars and molars.
oral health condition of an enrollee which existed before his/her enrollment in a dental program.
statement by a third-party payer indicating that proposed treatment will be covered under the terms of the benefit contract. See also precertification, predetermination.
confirmation by a third-party payer of a patient’s eligibility for coverage under a dental benefit program. See also Preauthorization, Predetermination.
interlocking device, one component of which is fixed to an abutment or abutments and the other is integrated into a fixed or removable prosthesis in order to stabilize and/or retain it.
an administrative procedure that may require the dentist to submit a treatment plan to the third party before treatment is begun. The third party usually returns the treatment plan indicating one or more of the following: patient's eligibility, guarantee of eligibility period, covered services, benefit amounts payable, application of appropriate deductibles, copayment and/or maximum limitation. Under some programs, predetermination by the third party is required when covered charges are expected to exceed a certain amount, such as $200. Also known as preauthorization, precertification, pretreatment review, prior authorization.
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.
Prefiling of Fees
the submission of a participating dentist's usual fees to a service corporation for the purpose of establishing, in advance, that dentist's usual fees and the customary ranges of fees in a geographic area to determine benefits under a usual, customary, and reasonable dental benefit program.
the use of medications prior to dental procedures.
the amount charged by a dental benefit organization for coverage of a 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 receipt of services.
Prepaid Group Practice
see Closed Panel.
When an eye doctor determines that corrective lenses are needed, she writes a prescription. The prescription is a concise description that includes all the details needed to create the desired lenses. Eyeglass or contact lenses that are created in this way are called prescription lenses.
term used by some dental benefit organizations to refer to the fee most commonly charged for a dental service in a given area.
refers to the procedures in dental practice and health programs which prevent the occurrence of oral diseases.
the first set of teeth; see Deciduous.
Proof of Loss
verification of services rendered expenses incurred by the submission of claim forms, radiographs, study models, and/or other diagnostic material.
scaling and polishing procedure performed to remove coronal plaque, calculus and stains.
prior assessment by a payer or payer’s agent that proposed services are appropriate for a particular patient, and/or the patient and the category of service are covered by a benefit plan. (See preauthorization, precertification, predetermination, second-opinion program.)
artificial replacement of any part of the body dental prosthesis - any device or appliance replacing one or more missing teeth and/or, if required, associated structures. (This is a broad term which includes abutment crowns and abutment inlays/ onlays, bridges, dentures, obturators, gingival prostheses); definitive prosthesis - a prosthesis to be used over an extended period of time; fixed prosthesis - non-removable tooth or implant borne dental prosthesis which is solidly attached to abutment teeth or roots or implants; interim prosthesis - a provisional prosthesis designed for use over a limited period of time, after which it is to be replaced by a more definitive restoration; removable prosthesis - dental prosthesis designed to be removed and reinserted by the patient.
a dental specialist whose practice is limited to the restoration of the natural teeth and/or the replacement of missing teeth with artificial substitutes.
formed or preformed for temporary purposes or used over a limited period; a temporary or interim solution; usually refers to a prosthesis or individual tooth restoration.
connective tissue that contains blood vessels and nerve tissue which occupies the pulp cavity of a tooth.
the space within a tooth which contains the pulp.
complete removal of vital and non vital pulp tissue from the root canal space.
inflammation of the dental pulp.
surgical removal of a portion of the pulp with the aim of maintaining the vitality of the remaining portion by means of an adequate dressing; pulp amputation.
program sponsor, often employer or union, that contracts with the dental benefit organization to provide dental benefits to an enrolled population.
one of the four equal sections into which the dental arches can be divided; begins at the midline of the arch and extends distally to the last tooth.
the measure of the quality of care provided in a particular setting.
the assessment or measurement of the quality of care and the implementation of any necessary changes to either maintain or improve the quality of care rendered.
pertaining to the root.
Reasonable and Customary (R&C) Plan
a dental benefit plan that determines benefits based only on “Reasonable and Customary” fee criteria. (see Usual Fee, Customary Fee, and Reasonable Fee.)
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 and by any medical or dental complications or unusual circumstances, and therefore may differ from the dentist’s “usual” fee or the benefit administrator’s “customary” fee.
process of refitting a denture by replacing the base material.
Reduced Fee For Services (RFFS)
a dental plan where all services are provided by professional dentists who agree to provide specific treatments and services to patients at reduced costs. There are no assigned dentists like a DHMO, so patients are free to see any dentist that contracts with that plan. With this freedom of choice patients are however responsible for a larger share of treatment costs.
Regional Block Anesthesia
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.
the return of a tooth to its alveolus.
insurance for third-party payers to spread their risk for losses (claims paid) over a specified dollar amount.
Relative Value System
coded listing of professional services with unit values to indicate relative complexity as measured by time, skill, and overhead costs. Third-party payers typically assign a dollar value per unit to calculate provider reimbursement.
process of resurfacing the tissue side of a denture with new base material.
Removable Partial Denture
a removable partial denture (removable bridge) is a prosthetic replacement of one or more missing teeth that can be removed by the patient.
Retail Store Dentistry
refers to dental services offered within a retail, department or drug store operation. Typically, space is leased from the store by a separate administrative group that, in turn, subleases to a dentist or dental group providing the actual dental services. The dental operation generally maintains the same hours of operation as the store and appointments often are not necessary. Considered to be a type of practice, not a dental benefit plan model.
orthodontic retainer - appliance to stabilize teeth following orthodontic treatment; prosthodontic retainer - a part of a fixed partial denture that attaches a pontic to the abutment tooth, implant abutment, or implant.
a method of sealing the root canal by preparing and filling it from the root apex.
a post-treatment assessment of services on a case-by-case or aggregate basis after the services have been performed.
a portion of provider fees or capitation payments withheld as financial reserves to cover unanticipated utilization of services in an alternative benefit plan.
the anatomic portion of the tooth that is covered by cementum and is located in the alveolus (socket) where it is attached by the periodontal apparatus; radicular portion of tooth; residual root remaining root structure following the loss of the major portion (over 75%) of the crown.
the portion of the pulp cavity inside the root of a tooth; the chamber within the root of the tooth that contains the pulp.
Root Canal Therapy
the treatment of disease and injuries of the pulp and associated periradicular conditions.
a procedure designed to remove microbial flora, bacterial toxins, calculus, and diseased cementum or dentin on the root surfaces and in the pocket.
removal of plaque, calculus, and stain from teeth.
Schedule of Allowances
see Table of Allowances.
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.
A security deposit in the amount of one month's premium will be held to be used in the event that automatic withdrawal is unavailable due to insufficient funds. Selecting monthly authorizes the withdrawal of this initial two (2) month premium plus the processing fee.
the method of providing employee benefits, in which the sponsor does not purchase conventional insurance, but rather elects to pay for the claims directly, generally through the services of a TPA. Self-funded programs often have stop loss insurance in place to cover abnormal risks.
setting aside of funds by an individual or organization to meet anticipated dental care expenses or its dental care claims, and accumulation of a fund to absorb fluctuations in the amount of expenses or claims. The funds set aside or accumulated are used to provide dental benefits directly instead of purchasing coverage from an insurance carrier.
dental benefit organizations established under not-for-profit state statutes for the purpose of providing health care coverage, e.g., Delta Dental Plans, Blue Cross and Blue Shield Plans.
one of the six relatively equal sections into which a dental arch can be divided, for example: tooth numbers 1-5; 6-11; 12-16; 17-21; 22-27; 28-32. Sometimes used for recording periodontal charting.
surgical procedure for the repair of a defect and/or restoration of portion of a salivary gland duct.
inspection of the salivary ducts and glands by radiograph after the injection of a radiopaque medium.
surgical procedure by which a stone within a salivary gland or its duct is removed, either intraorally or extraorally.
a term used to describe a single area, position, or locus. A single site is an area of communication that may involve adjacent teeth. All non-communicating areas are single sites.
a device used to support, protect, or immobilize oral structures that have been loosened, replanted, fractured or traumatized. Also refers to devices used in the treatment of temporomandibular joint disorders.
Statistically-based Utilization Review
a system that examines the distribution of treatment procedures based on claims information and in order to be reasonably reliable, the application of such claims analyses of specific dentists should include data on type of practice, dentist's experience, socioeconomic characteristics, and geographic location.
inflammation of the membranes of the mouth.
a general term referring to that category of coverage that provides insurance protection (reinsurance) to an employer for a self-funded plan.
that part of a tooth-borne and/or tissue-borne prosthesis designed to relieve the abutment teeth and their supporting tissues from harmful stresses.
plaster or stone model of teeth and adjoining tissues; also referred to as diagnostic cast.
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.
Summary Plan Description
see Benefit Plan Summary.
a stated dollar amount paid to the dentist by the beneficiary, in addition to other reimbursement received by third-party payer(s).
stitch used to repair incision or wound.
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 service, but does not necessarily represent the dentist’s full fee for that service. Also known as schedule of allowances, indemnity schedule.
Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA):
legislation (Public Law 97-248) affecting health maintenance organizations and the Medicare and Medicaid programs. Provides regulations for the development of HMO risk contracting with the Medicare program and, through amendment, established new provisions for the foundation and operation of peer review organizations.
Temporary Removable Denture
an interim prosthesis designed for use over limited period of time.
the connecting hinge mechanism between the base of the skull (temporal bone) and the lower jaw (mandible).
Temporomandibular Joint Disfunction
abnormal functioning of temporomandibular joint; also refers to symptoms arising in other areas secondary to the disfunction.
see Expiration Date.
the party to a dental benefit contract that may collect premiums, assume financial risk, pay claims, and/or provide other administrative services. Also known as administrative agent, carrier, insurer, underwriter.
Third-Party Administrator (TPA)
claims payer who assumes responsibility for administering health benefit plans without assuming any financial risk. Some commercial insurance carriers and Blue Cross/Blue Shield plans also have TPA operations to accommodate self-funded employers seeking administrative services only (ASO) contracts.
an organization other than the patient (first party) or health care provider (second party) involved in the financing of personal health services.
material intended to be placed in contact with tissues, for a limited period, with the aim of assisting the return to a healthy condition.
a bony elevation or protuberance of bone; see Exostosis.
relating to a passage or change from one position, state, phase or concept to another.
Transplantation of Tooth
transfer of a tooth from one socket to another, either in the same or a different person.
through or across a septum.
restricted ability to open the mouth, usually due to inflammation or fibrosis of the muscles of mastication.
Unbundling of Procedures
the separating of a dental procedure into component parts with each part having a charge so that the cumulative charge of the components is greater than the total charge to patients who are not beneficiaries of a dental benefit plan for the same procedure.
tooth/teeth that have not penetrated into the oral cavity.
one-sided; pertaining to or affecting but one side.
using a procedure code which reflects a higher intensity service than would normally be used for the services delivered.
the fee that an individual dentist most frequently charges for a given dental services. (see also Customary Fee and Reasonable Fee.)
Usual, Customary and Reasonable (UCR) Plans
a dental benefit plan that determines benefits based on "Usual, Customary, and Reasonable" fee criteria. (See Usual Fee, Customary Fee, and Reasonable Fee.)
1) The extent to which the members of a covered group use a program over a stated period of time; specifically measured as a percentage determined by dividing the number of covered individuals who submitted one or more claims by the total number of covered individuals. 2) An expression of the number and types of services used by the members of a covered group over a specified period of time.
is a set of techniques used by or on behalf of purchasers of health care benefits to manage the cost of health care prior to its provision by influencing patient care decision-making through case-by-case assessments of the appropriateness of care based on accepted dental practices.
Utilization Review, statistically based
a system that examines the distribution of treatment procedures based on claims information and in order to be reasonably reliable, the application of such claims analyses of specific dentists should include data on type of practice, dentist’s experience, socioeconomic characteristics, and geographic location.
in the construction of crowns or pontics, a layer of tooth-colored material, usually, but not limited to, composite, porcelain, ceramic or acrylic resin, attached to the surface by direct fusion, cementation, or mechanical retention; also refers to a restoration that is luted to the facial surface of a tooth.
any of a series of surgical procedures designed to increase relative alveolar ridge height.
Similar to health or dental insurance, vision insurance provides coverage for issues related to eye health. There are a wide variety of plans available with and without copayments from a number of companies. Most vision insurance policies include yearly exams and full or partial coverage for glasses, contacts, and sunglasses.
the period between employment or enrollment in a dental program and the date when a covered person becomes eligible for benefits.
a wax form that is the positive likeness of an object to be fabricated.
decreased salivary secretion that produces a dry and sometimes burning sensation of the oral mucosa and/or cervical caries.
a general term for a fungus occurring as a unicellular, nucleated organism that usually reproduces by budding, although some yeasts may reproduce by fission, many producing mycelia or pseudomycelia.
quadrangular bone on either side of face that forms the cheek prominence (see Malar).