Dental Benefit Terminology

The world of dental benefits can be a little confusing if you don't know these words.

  • AUDIT/EDIT REPORT

    A report from a clearinghouse that lists errors that need to be corrected before a claim can be submitted to the insurance carrier.

  • CAPITATION

    A type of managed care system (like an insurance) in which patients pay fixed rates at regular intervals. Payments are made on a regular basis from an insurance carrier to a provider for providing to plan members.

  • CLAIM

    A submission to a dental insurance company that includes patient and subscriber information, coded procedures, treatment fees, and doctor information and requests payment to be made for service.

  • CLEARINGHOUSE

    A service bureau that collects electronic insurance claims and forwards them to the appropriate insurance company.

  • COINSURANCE

    The percentage of costs of a covered health care service that the patient must pay after deductible (20%, for example).

  • CO-PAYMENT

    The amount the insured person must pay for each health care encounter.

  • DATE OF SERVICE

    The date a particular dental procedure was performed.

  • DEDUCTIBLE

    An amount set by the insurance company that the patient must pay before the insurance company will begin to pay.

  • DENTIST’S PRETREATMENT ESTIMATE

    A dentist’s estimate of needed dental work that is submitted to an insurance carrier before the service is performed to determine a patient portion estimate for the patient.

  • DOWNGRADE

    The insurance company will sometimes cover a less expensive alternative procedure. For example, composite (tooth colored) fillings are often downgraded to amalgam (silver) fillings.

  • ELECTRONIC FUNDS TRANSFER (EFT)

    A system that transfers money electronically from one account to another.

  • ELECTRONIC REMITTANCE ADVICE (ERA)

    An electronic explanation of benefits.

  • EXCLUSIVE PROVIDER ORGANIZATION (EPO)

    Similar to an HMO. Lower out of pocket expense than a PPO for a patient, and no payment is made by plan if patient sees an out of EPO network doctor.

  • EXPLANATION OF BENEFITS (EOB)

    A document from an insurance carrier that lists the amount of a benefit and explains how it was determined.

  • GROUP NUMBER

    A number assigned to a specific group signifying a particular dental plan.

  • HEALTH MAINTENANCE ORGANIZATION (HMO)

    A fixed amount that is paid to a dentist in advance to provide medically necessary services to the patient. If the practice is NOT an HMO provider, there will be no benefits paid for patients who have an HMO plan.

  • INDEMNITY

    Compensation paid to dentists based on an amount per service. A fee-for-service plan generally permits enrollees to freely select a network or non-contracted dentist to provide the service.

  • INSURANCE CARRIER

    A company that offers financial protection as a result of a specific event.

  • MAXIMUM

    The maximum dollar amount a dental benefit plan will pay toward the cost of dental care within a specific benefit period (typically January through December). The patient is personally responsible for paying costs above the annual maximum.

  • MISSING TOOTH CLAUSE

    Describes a situation in which benefits are not payable to replace a tooth that was extracted prior to having dental coverage. If a patient has a missing tooth clause, then prior extractions (under a different plan) are NOT covered under this plan.

  • PAYER

    Private or governmental organization that insures or pays for health care on behalf of the beneficiaries

  • POLICYHOLDER (member, subscriber, insured)

    A person who buys the insurance plan.

  • PREFERRED PROVIDER ORGANIZATION (PPO)

    Network of health care providers who agree to perform services for plan members at discounted fees.

  • PREMIUM

    The amount an insured pays to an insurance company for an insurance plan.

  • PROCEDURE CODE

    A code that identifies dental services.

  • REFERRING PROVIDER

    A dentist who recommends that a patient see another specific dentist or specialist.

  • RESPONSIBLE PARTY

    The person held accountable for a specific patient’s fees.

  • SUBSCRIBER

    The person in the family who carries the dental coverage.

  • USUAL AND CUSTOMARY RATE (UCR)

    The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.

  • WAITING PERIOD

    The length of time after purchasing a dental benefits plan that a patient must wait before coverage for certain procedures goes into effect.