Glossary

Grinding or wearing away. (See Bruxism)

A localized area of inflammation containing pus.

A tooth or implant that retains or supports a fixed bridge or a removable prosthesis. The abutments may be crowns, onlays, or inlays. Sometimes referred to as a retainer.

In restorative dentistry, a method of etching the tooth enamel with an acid to provide an adhesion of the composite filling material to the tooth surface.

An arrangement under which a third party charges a fee to process claims and handle paperwork for a self-funded group. The third party frequently performs all insurance company services (actuarial, underwriting, plan materials and descriptions, claims processing, etc.) except for the assumption of risk and the cost of paying claims. (Compare to CSO)

In dentistry, refers to procedures that have a particularly evident cosmetic purpose. For example, bleaching or tooth-whitening, composite restorations (white fillings), porcelain prosthetics and veneers.

To move teeth into position for a proper line of occlusion (bite).

Also called a Claim Allowance Option. The method used on an eligible procedure to determine the maximum covered dollar amount considered. Allowance Methods are an integral part of a plan design and are defined in the group policy contracts and in each member certificate booklet. Some examples of Allowance Methods:

1. Usual and Customary (U&C)
2. Scheduled Allowances (SCU)
3. Maximum Allowable Charge on PPO plan (MAC)
4. Maximum Allowable Benefit (MAB)
5. Maximum Procedure Allowance (MPA)

Please refer to your certificate booklet to see what Allowance Method design is used for your plan.

A mixture of two or more metals, as in silver amalgam fillings.

A provision in a dental plan that allows the third-party payer (insurance company) to determine the benefit payable based on an alternative procedure than the one provided or proposed. This is not intended to determine treatment but to establish benefits payable. This provision is designed into many dental plans because there are often alternate methods of treatment for the same condition in dentistry. In some cases there may be a less expensive service that is customarily perform ed for the given situation. In such cases, a more expensive alternate procedure may be preferred by the dental provider or the patient, or may have a cosmetic element involved. For example, a molar tooth that is being restored with a composite (white) filling will be reimbursed at the alternate benefit level of an amalgam (silver) filling.

Of or relating to the bony socket containing the root of a tooth. (See Alveolus)

The part of the bone in each arch of the mouth that surrounds and supports the teeth. (See Alveolus)

In each arch of the mouth, the ridge, line, or junction where the bone supporting the teeth meets the bony sockets containing each tooth root. (See Alveolus)

The surgical removal of part of the bone that supports the teeth. (See Alveolus)

Plural of alveolus. (See Alveolus)

In dentistry, the bony socket for the root of the tooth. A small pit or hollow. The plural form is alveoli. The root sockets in each arch are supported and surrounded by a bone structure called the alveolar process. The line or junction where the root sockets meet the surrounding bone structure is the alveolar ridge. Surgical removal, contouring or restructuring of the alveolar process is called alveoplasty.

Surgical removal or correction of the alveolar process to restore a normal contour. It can range from surgical removal (alveolectomy) in conjunction with extractions to necessary reconstruction of the ridge in preparation for dentures. (See Alveolus)

Dental amalgam filling is an alloy of silver, tin, mercury, and other metals, used as a restorative material. (See Composite versus Amalgam restorations)

Surgical removal of the root portion of the tooth. It is usually performed on a multi-rooted tooth to eliminate a root that cannot be treated.

Reduction (or loss) of sensibility to pain without loss of consciousness.

Loss of feeling, or sensation, with or without loss of consciousness.

Drugs used to produce loss of feeling or sensation, either as local or general anesthesia.

The period of time preceding the effective or anniversary date of a group insurance policy that allows eligible group members to participate or not participate. If a member elects to enroll after his/her initial 31 days of eligibility, even during an Annual Enrollment, there is usually a “Late Entrant” penalty imposed. Annual Enrollment differs from Open Enrollment. Questions about enrollment and Late Entrant provisions should be addressed with your Benefit Administrator. (See Open Enrollment and Late Entrant)

In the front. With reference to teeth, the anteriors are incisors and cuspids. (See Tooth Number Chart)

The anatomic end of the tooth root. (See Tooth Diagram)

Normally performed on a young patient where the apex of a tooth is incompletely formed. The pulp is removed and the apex treated with calcium hydroxide. This stimulates the growth of cementum, which promotes apical closure. Root canal therapy would usually be performed at a later time.

Refers to the apex of the tooth root.

Surgical removal of the end portion of the tooth root. It is performed through an opening (or window) made in the overlying labial or buccal alveolar bone.

In dentistry, a device used to replace missing parts, to provide function, or for therapeutic purposes. They include dental prostheses, splints, and orthodontic appliances.

In dentistry, a curved structure of the natural dentition or alveolar ridge. The two arches in the mouth are the maxilla (upper jaw) and mandible (lower jaw). (See Tooth Number Chart)

Free from germs and infection.

Transferring the insurance payment to the doctor providing the services. Signing the Assignment of Benefits signature line on a claim form authorizes payment directly to the doctor’s office.

A form the patient receives from the dentist or specialist that has the pertinent information regarding services received. Also called a walk-out statement. Please refer to section #2 of the claim form for more information.

The wearing away of a substance, abrasion. (See Bruxism)

When a dentist or specialist charges the patient the difference between the amount reimbursed or expected from the insurance company and the dentist or specialist fees.

A category of coverage for oral procedures. The other categories are Preventive and Major. Each category may have a different coinsurance or deductible applied. See your Certificate Booklet to find out which procedures fall under which category.

The amount payable by a third party (insurance company) toward the cost of various covered dental services.

The representative of the Plan Sponsor who coordinates the group policy, working with the insurance carrier(s).

Benefit credit is established by the secondary carrier, when an insured member has more than one dental plan. Benefit credit is established when the benefits of both carriers combine to equal more than the actual expenses incurred. When a later claim is received for an eligible procedure that is not paid in full between the two carriers, the amount in benefit credit will be released to pay the difference. When benefit credit is earned or paid, it will be noted on your Benefit Statement. (See Coordination of Benefits)

The period of time defined in the policy that certain records are kept or individual benefits are paid. Typically, a Benefit Period determines when the yearly maximum and the yearly deductible renew. The beginning date may vary depending on the plan. Please refer to your online benefits, certificate booklet, or Plan Sponsor. Follow the links for more detailed explanations of Benefit Period types:

1. Calendar Year – Jan 1 to Dec 31 of the same year.
2. Policy Year – The calendar, policy, benefit or fiscal year on which the records of a plan are kept and/or benefits are paid.
3. Plan Year – Usually set by the group’s effective date or a group’s fiscal year.
4. Employee Year – Set by the employee/plan member’s effective date and applies to a family.
5. Dependent Year – Set by each individual person’s effective date.

A statement the insured member receives summarizing the processing of a claim. The statement includes services performed, dates of service, provider identification, a summary of charges and explanations of payment or denial. Also called Explanation of Benefits (EOB) or Claim Explanation.

The two teeth in each quadrant behind the cuspids and in front of the molars. (See Tooth Number Chart)

Involving two quadrants, or both sides of an arch.

See Night Guard and Bruxism.

Dental X-ray films that normally show approximately the crown portions of both the upper and lower teeth on the same film.

A technique used to restore a discolored tooth to its natural color.

(Fixed) Restores the continuity of the dentition by replacing missing natural teeth with artificial teeth (pontics) which are attached to, and supported by, abutments or retainers. The abutments may be crowns, onlays or inlays. The pontics are usually supported between two abutments; however, a cantilevered bridge has abutments on just one side of the pontic. (Removable) A partial denture retained by attachments permitting its removal. It is generally a one-piece metal casting, with denture teeth to replace missing natural teeth. It is held in place by clasps. Units of removable bridges include the teeth and the clasps.

A clenching or grinding of the teeth, associated with a forceful jaw movement, usually during sleep. It is a habit frequently related to emotional stress, anxiety, fatigue, or bite interference. Bruxism may grind away at and/or fracture teeth. Untreated, the condition may affect a person’s entire bite (occlusion) causing temporomandibular joint (TMJ) problems and/or periodontal disease. Dental plans rarely cover the treatment of Bruxism and TMJ because the underlying cause is typically a condition other than dental decay. Coverage through one’s medical insurance should also be investigated. (See TMD/TMJ)

See Night Guard and Bruxism.

The surface of the tooth toward the cheek. (See Tooth Number Chart)

A type of benefit plan where enrollees select from a list of nontaxable benefit options. The insured members’ premium payments are funded with pre-tax employee contributions. Available plan options may include, but are not limited to, medical, dental, and eye care. The tax code allowing Cafeteria Plans restricts enrollment and cancellation to one opportunity each year plus certain qualifying events. Cafeteria Plans are also called Flex or Section 125 plans.

The period of time from January 1 of any year through December 31 of the same year. On a Calendar Year plan, the benefit Period for someone who becomes effective on a date other than January 1 is their effective date through December 31 of the same year, then January 1 to December 31 subsequently. (See Benefit Period)

A plan’s payment limit in actual dollars toward the services performed during a particular Calendar Year. unless otherwise stated in policy, the limit applies to all payable procedures including routine exams and cleanings. (See Calendar Year)

A tubular passage or channel. A root canal is the space within the root of a tooth that contains the pulp tissue.

A dental prosthesis, usually a fixed bridge, where the fake tooth (pontic) is supported by abutments or retainers on just one side.

See DHMO.

Used in the Prepaid or Dental Health Maintenance Organization (DHMO) environment, this amount is paid to each general dentist proportionate to the number of members who have selected him/her as their primary general dentist.

A covering for a slightly exposed healthy pulp, with a material that will protect and stimulate the formation of secondary dentin. Calcium hydroxide is frequently used.

Provides a direct contact between the material used and the pulp.

Is application of the material to diseased dentin, usually not a covered benefit.

A progressive destruction of the teeth from bacterially produced acids on tooth surfaces. A localized progressive disintegration of tooth structures – tooth decay. An irreversible disease.

A carious lesion in a tooth. Damage to a tooth from decay.

In dentistry, material used to provide a seal and to cement restorations and appliances to teeth.

The hard, calcified tissue that covers the anatomic root of a tooth. (See Tooth Diagram)

The booklet issued to an insured member that contains dental benefits and limitations.

Abbreviation for child found on some dental Benefit Statements.

A statement listing services rendered, the dates of services, and an 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.

See Allowance Method.

See Benefit Statement.

An arrangement in which claims are processed and payments released by a contractor rather than by the organization bearing the risk of coverage. Under this arrangement, administrative services are not included with the claim services. A self-insured, self-administered group usually seeks this type of arrangement to take advantage of the claims handling expertise provided by an insurance company, processing service center, or third party administrator. (Compare to ASO)

A metal attachment on partial dentures or other removable appliances to hold them in place. They are designed to adapt to the clasping teeth to provide maximum stability. There are many kinds of clasps, but they generally consist of two arms joined by a body that may or may not have an occlusal rest.

Federal legislation relative to continuation of health benefits for all types of employee plans that are provided by employers having twenty or more employees. The most significant aspect is the requirement that employees and/or their dependents who become ineligible for coverage may purchase continued coverage for an additional 18 months (36 months for dependents in the event of an employee’s death). Employers operating under Multiple Employer Trust (MET) such as Plan Services are treated as maintaining separate plans, and thus each of the employer units having fewer than 20 employees is exempt from COBRA regulations. Benefit Administrators are responsible for coordinating COBRA coverage options for the insured member and/or dependents.

An arrangement that apportions (assigns) expenses between health plan participants and the insurer. The insured member shares in the cost of covered services, generally on a percentage basis. Coinsurance is based on the plan’s Allowance Method and other plan provisions.

A denture that replaces all of the teeth in an arch.

A white or tooth-colored resin restorative material. (See Composite versus Amalgam restorations)

Restorations, such as fillings, are typically made of either a composite material or of an amalgam of metals. Composites are tooth-colored or white in appearance and typically have a higher fee and allowance than amalgams, which have a metallic silver appearance. On visible (anterior) teeth requiring restorative treatment, most plans provide benefits for composite (white) fillings. But on molar teeth, most plans will limit the allowance to the equivalent of the silver amalgam filling even if composites are performed. Both materials provide restorative quality. An individual and his or her dentist may decide to place the composite material on a molar tooth for a number of reasons, none of which will change the limitation of the silver amalgam allowance limit on plans with an Alternate Benefit Clause.

A type of plan in which the Plan Sponsor pays the full cost of the premium and has agreed to enroll all eligible members.

Charges for services rendered or supplies furnished by a dentist or specialist that qualify as covered services and may be paid for in whole or in part by the dental plan. May be subject to deductibles, coinsurance, or Allowance Methods as specified by the terms of the contract.

A plan in which a portion or all of the premiums are paid by the insured members.

When an insured member is covered by two separate dental plans, the expenses incurred are usually considered by both plans. In order to coordinate, the secondary carrier must obtain a copy of the Benefit Statement issued by the primary carrier. The total payment from all plans is limited to the actual costs due the dentist. Not all plans coordinate benefits. Coordination of Benefits is necessary so that an insured member or dental office does not receive more benefits than the actual expenses incurred.

The maximum allowed dollar amount per eligible procedure upon which deductibles, coinsurance and other plan options are applied.

With prosthetic tooth structure, an artificial cap designed to restore proper conditions to a damaged tooth.

A surgical instrument that has a sharp, spoon-shaped blade. It is used for debridement, root planing and gingival curettage.

Scraping or removal of diseased tissue with a curet.

A pointed or rounded high point on the biting or chewing surface of a tooth.

The four pointed teeth located between the lateral incisor and first bicuspid in each quadrant of the mouth. They are considered to be the keystones of the arch. Sometimes referred to as the canine teeth. (See Tooth Number Chart)

Generally, the actual date a service was performed. For claim determination, we define dates of services as follows: For prosthetics, the “impression” date rather than the delivery date. For root canals, the start or opening date rather than the completion date. For orthodontic treatment programs, the banding date.

Removal of diseased or devitalized tissues and foreign material.

Decomposed tooth structure; caries or carious lesions of the teeth.

The first teeth to erupt in childhood. Also called the “baby teeth.”

A specified amount of eligible expenses that must be incurred and paid by the insured member prior to any benefits being paid. ineligible or non-covered expenses do not count toward satisfaction of a deductible. Deductible may be annual, lifetime, quarterly, or daily and may vary in amount from plan to plan. Your deductible may vary for different procedure categories based on your plan design.

• Individual Deductibles Deductibles applied per person. They may be limited by a Family Deductible depending on the plan.
  • Annual Deductible Deducted yearly on the plan’s Benefit Period. The amount is reapplied each year. Also called a Yearly Deductible.
  • Calendar Year Deductible An Annual Deductible that resets on January 1st of each year.
  • Lifetime Deductible Deducted once during the duration of the policy. It does not reapply each year.
  • Three Month Carryover Refers to the deductible of this plan. If the insured member satisfies the deductible in the last three months of the current Benefit Period, the deductible will carry over into the next Benefit Period. Because of this, the insured member does not need to satisfy the deductible in the new Benefit Period.
  • Quarterly Deductible Deducted each quarter, usually only used with Calendar Year plans:
    • quarter #1 = January, February, March
    • quarter #2 = April, May, June
    • quarter #3 = July, August, September
    • quarter #4 = October, November, December
  • Daily (per-visit) Deductible Deducted from each billed visit.
• Family Deductibles A feature of some plans that limits the cumulative dollar amount of an Individual Deductible or the cumulative number of Individual Deductibles that must be met by a family.
• Aggregate Amount Family Deductible Refers to a specific cumulative dollar amount of Individual Deductibles that when satisfied may waive further application of deductibles for the family. There may be variations.

Refers to a specific number of family members who must each fully satisfy their Individual Deductible for remaining Individual Deductibles to be waived on the family. There may be variations.

The branch of dental science that deals with the replacement of missing teeth and related structures of the mouth.

Cutting into or on live tissue in the mouth.

The hard tissue that forms the bulk of the tooth. The crown portion is covered with enamel and the root portion with cementum. (See Tooth Diagram)

One who has the legal right to treat disease and injuries to the teeth or mouth and construct and insert restorations. (See Specialist)

Once erupted, the natural teeth in the dental arch. Dentition may be made up of the primary teeth, permanent teeth or a combination.

A prosthesis replacing missing teeth.

To add new material to the surface of a denture that contacts the oral tissue in order to provide a better fitting denture.

An insured member’s spouse and all unmarried children up to age 19 for whom the Insured member is legally responsible. In some states and/or plans, dependents are defined differently. This definition applies to the majority of states. This also includes an unmarried child 19 to 24 years of age who is a full-time student at an accredited school or college and who is dependent primarily on the Insured for support or maintenance. This definition may also include a mentally or physically handicapped child who is totally disabled since the day before his or her nineteenth birthday and who is totally dependent on the Insured for support and maintenance.

A type of Benefit Period arranged by the Plan Sponsor where each insured member’s Benefit Period is set by his/her own effective date on the policy. If the insured member covers his/her dependents, they may each have a different Benefit Period renewal date than the insured member depending on when each person became effective.

Defined as a Dental Health Maintenance Organization, this is a legal entity consisting of a network of participating dental providers that provide or arrange dental care with fixed fees for a given population. Dental providers receive Capitation payments based on the number of members who have selected them as their primary general dentist. No benefits are payable for dental procedures from a out-of-network dentist. We do not maintain any DHMO networks.

A positive replica of the teeth and tissues made from an impression.

Away from the front and center of the mouth or closer to the back of the mouth — the distal surface of a tooth. (See Tooth Number Chart)

When a Plan Sponsor has multiple locations, plants, subsidiaries, etc., their policy may be categorized into divisions. Divisions may be used to identify differences in benefits among the divisions or simply for a group’s accounting purposes.

A benefit package from which an eligible individual can choose to enroll in either a traditional (indemnity) or prepaid dental benefit program.

Developmental abnormality; alteration in size, shape or function.

An area without teeth.

Sometimes referred to as an “eligibility” date. The date an individual or dependent became active under a dental plan. There may be a Late Entrant provision and/or an Elimination Period applicable, as well as other plan provisions.

A group member who meets the eligibility requirements specified in the group contract to qualify for coverage. It may be necessary to fulfill the group’s eligibility period before becoming eligible. (See Procedure Eligibility)

A period of time a person must be a member of a group before qualifying for group benefits. For example, an organization whose health and dental benefit plan has a 90-day eligibility period would require 90 days of qualified employment/membership before benefits could begin. An Eligibility Period should not be confused with an Elimination Period.

A time period within the structure of a plan beginning immediately on an insured member’s effective date that must be satisfied before benefits on certain procedures become available. Because Elimination Periods are sometimes called Waiting Periods, care should be taken not to confuse the two terms. (See Eligibility Period)

See Member Contribution.

A type of Benefit Period arranged by the Plan Sponsor where each employee/member’s Benefit Period is set by his/her own effective date on the policy. If the member covers his or her dependents, they have the same Benefit Period renewal date as the insured member.

Tooth enamel is the white, compact and very hard substance that covers the coronal portion of the tooth and protects the dentin.

The branch of dentistry focusing on diseases of the tooth root, dental pulp chamber, and the surrounding tissue. A “root canal (therapy)” is an endodontic procedure.

A cast designed to fit into the endodontically treated root canal of a tooth. It provides strength and stability in supporting the crown and surrounding tooth structure.

Wearing away of tooth structure by action of a chemical agent or by mechanical wear.

Generally, a tooth that has broken through the gingival tissue, becoming visible in the mouth.

In dentistry, investigating the mouth for diagnostic purpose. There are many distinct types of examinations. The nature of the appointment, the purpose of the examination, the amount of area examined, and the length of the examination are all factors in determining what type of examination was performed.

See Missing Tooth/Existing Space.

See Benefit Statement.

A statement the dentist or specialist receives summarizing the processing of the claim. The statement includes services performed, dates of service, provider identification, a summary of charges and explanations of payment or denial. This statement may have more than one patient listed.

Removing a tooth from the mouth.

Outside the mouth.

Pertaining to the face. The surface of a tooth or appliance nearest to the lips or cheeks.

A system of payment or reimbursement in which the dentist or specialist is paid according to the service performed. This is the reimbursement system used by conventional indemnity insurers.

Preferred term is restoration. Filling refers to the restorations not requiring crowns.

A prosthesis that replaces one or more teeth and is cemented into place. It consists of one or more pontics held in place by one or more retainers or abutment teeth. (See Bridgework)

A bridge where pontics may be removed in a semi-permanent type of construction by use of a tubes and screws.

See Stayplate.

A solution of fluorine that is applied topically to the teeth for the purpose of preventing dental caries.

Used in context with a managed care dental plan, the insured member has the freedom to choose any dentist or specialist whether on the PPO network or not.

The surgical removal of the mucous membrane that attaches the cheeks and lips to the upper and lower arch or the surgical removal of the lingual tissue (frenum) that attaches the tongue to the floor of the mouth and the alveolar ridge.

A fold of mucous membrane in the mouth connecting two parts and limiting motion.

Benefit information that advises how often certain procedures can be covered under the dental plan. For Example: One cleaning every 6 months.

Usually 14 x-ray films consisting of 10 periapical films and 4 bitewing films.

Coverage for the initial placement of any prosthetic appliance (partials or dentures) or fixed appliance (bridge) to replace an extracted tooth or teeth. This coverage will be provided even if the teeth were lost prior to being insured.

An overview of a dental plans benefits and limitations, including coinsurance, deductible, and maximums.

The fibrous tissue covered by mucous membrane that surrounds the teeth and covers the supporting bone of each arch.

Surgical removal of diseased or unsupported gingival tissue; elimination of periodontal pockets and/or creation of new gingival margin.

Inflammation of the gingival tissue.

The procedure by which gingival deformities are reshaped and reduced to create normal and functional form; surgical contouring of the gingival tissues.

An acrylic resin appliance designed to stabilize and protect the teeth from traumatic effects of bruxism or other bad occlusal habits. (See Bruxism)

See Gingiva.

In most states, a dental hygienist is a person trained and licensed by the state to perform routine cleanings under the direction of a licensed dentist. The work is often limited to routine prophylaxis cleaning.

See Appliance.

A complete or partial denture that is made before the natural teeth are extracted. It is inserted at the time the teeth are extracted. The technique differs from a conventional denture, which is made after the teeth have been extracted and the area has healed.

Commonly, any tooth that is positioned or wedged against another tooth, bone or soft tissue, preventing it from erupting normally. The anatomical position of the tooth in relation to the surrounding features determines the type of impaction.

Dental implants are prostheses made of metal or other foreign material that is placed into or on the alveolar bone to provide support.

In the mouth, a negative reproduction of the teeth and/or other tissues of the mouth. A positive reproduction is made from the impression and used in preparation of restorations such as crowns, fixed and removable prostheses, and appliances. Impressions are also used to make models for diagnostic purposes.

See Incentive Program.

A plan feature in which the insurance company pays an increasing share of the treatment cost until a maximum level of coverage is reached. An incentive level increase is subject to the covered individual receiving treatment at least once each Benefit Period (usually a calendar year). Failure to visit the provider during a Benefit Period typically results in reverting back to the base or initial coinsurance level.

The cutting edge of the anterior teeth.

A cutting tooth; the central and lateral incisors, which are the four anterior teeth of the upper and lower arches. (See Tooth Number Chart)

An expense is considered to be incurred at the time service is rendered.

Often called a Traditional plan. The key characteristic of this plan is the freedom to choose your own dentist or specialist. The insurance payment may be made directly to the dentist or specialist, via Assignment of Benefits, or to the member. Usually requires a properly completed claim to be filed in order to obtain reimbursement(s).

Tissue response to irritation or injury, characterized by heat, swelling, redness and pain.

A person enrolled in the policy on the same date the plan takes effect for the entire group or division.

A restoration of metal, porcelain, or plastic made to fit a tooth cavity preparation and then cemented into place. Plans usually provide the Alternate Benefit of a filling for an Inlay.

The benefits available to an insured member of a PPO plan when visiting a contracted member of our PPO network. Also known as In-panel Benefits.

A person who is a member of the plan – the insured member may also cover his/her dependents on most plans. (Other terms used for insured member are: member, subscriber, employee, covered person, eligible person, enrollee, beneficiary)

Inside, or within, the mouth.

A common termed used to describe both the lower (mandible) arch or jaw and its supporting bone structure. Also applicable to the upper (maxilla) arch or jaw and its supporting bone structure.

Pertaining to the lips. The surface of an anterior tooth facing the lips. (See Tooth Number Chart)

See Porcelain Laminate.

If an insured member or dependent enrolls later than 31 days after becoming eligible, the person is considered a late entrant. if you are considered a late entrant, refer to your certificate booklet to determine if there are limitations established by your group plan.

An anterior tooth located just behind the central incisor. The second tooth from the midline. (See Tooth Number Chart)

See Nitrous Oxide.

The insured member’s obligation for a specified amount or service. (See Out-of-Pocket Expense)

The maximum benefit payable toward covered expenses incurred by an individual during his or her lifetime under the policy. Lifetime maximums are a common feature among orthodontic policies.

Conditions stated in a dental benefit contract, such as age, pre-existing conditions, benefit elimination periods, and late entrant provisions, which affect an individual’s or group’s coverage.

Pertaining to the tongue. The surface of a tooth or prosthesis next to the tongue. (See Tooth Number Chart)

A category of coverage for oral procedures. The other categories are Preventive and Basic. Each category may have a different coinsurance or deductible applied. See your Certificate Booklet to find out which procedures fall under which category.

A broad term that describes many types of health care arrangements and plans. It typically refers to plans with benefit restrictions based on the type and frequency of treatment, where treatment may be obtained, and how much is paid toward the actual cost of treatment. it is an approach to controlling the utilization and cost of dental care using a variety of cost-containment methods, with an emphasis on creating incentives for insured members to choose less expensive treatments.

The lower jaw or lower dental arch. (See Tooth Number Chart)

Technically, the bone forming one-half of the upper jaw. The upper jaw consists of two maxillae; however, it is commonly referred to as the maxilla, in dentistry. The maxilla is stationary, as opposed to the mandible, which is a moving and projecting bone.

Pertaining to the jaws and face. Maxillofacial surgeons perform surgery related to the jaws and face such as the surgical removal of impacted wisdom teeth.

Applied to a Non-PPO plan. MAB is an Allowance Method based on the fees general dentists of a PPO network would agree to accept in that area. Watch this quick MAC/MAB video for a simple explanation of how dental claims are paid with a MAB out-of-network claim allowance.

Applied to a PPO plan. MAC is an Allowance Method based on the fees general dentists of a PPO network would agree to accept in that area.

The maximum dollar amount a dental plan will pay toward the cost of dental care incurred by an individual or family in a specified Benefit Period, typically a calendar year.

An Allowance Method based on the median (middle) of charges received by insurance carriers from general dentists within a ZIP code area. The MPA is reviewed and updated periodically to reflect increasing provider fees.

Abbreviation for member.

An individual enrolled in a group benefit plan, usually through his or her employer or union. Other terms used for the member are: insured, insured member, subscriber, enrollee, and employee.

The portion of the insurance premium paid by the insured member to participate in a group plan. Also known as employee contribution on employer-sponsored plans.

A metal that is liquid at room temperature. In dentistry, it is mixed with the silver alloy in the making of amalgam restorations.

The surface of a tooth nearest to the front and center of the mouth in a normal occlusion (bite). (See Tooth Number Chart)

The imaginary dividing line through the middle of an object or space.

A space in the mouth where a tooth has been extracted. Most dental plans have takeover provisions in place to limit the coverage available for a space that existed prior to the member’s effective date. Generally, the replacement of a tooth congenitally or otherwise missing, lost due to accident or extracted prior to a person’s effective date is not eligible for any benefits toward a bridge, partial, denture, implant, etc. (See Missing Tooth Clause)

The section of a dental plan that explains the coverage limitations relating to teeth missing or extracted prior to one’s effective date of coverage. There are many variations. (See Missing Tooth/Existing Space)

The three teeth in the back of each quadrant of the mouth that are located behind the second Bicuspids. They are used for grinding. in normal dentition, the molar farthest back in each quadrant is a “wisdom tooth.” (See Tooth Number Chart)

A group of dentists and specialists that have agreed to a carrier’s contract and fee levels to perform services on insured members under a managed care arrangement. Also called panel providers. (See Participating Provider Organization)

An appliance that covers the biting surfaces of teeth. It is used to stabilize the teeth and/or provide a flat surface for unobstructed movement of the mandible. Also called occlusal guard, bite guard, and bruxism appliance. (See Bruxism)

In combination with oxygen, it can be used as a general anesthesia. It is ordinarily used to achieve a light state of general anesthesia. The patient remains conscious but less sensitive to pain. It is also referred to as “laughing gas.”

A method of payment for group coverage in which the entire monthly premium is paid by the Plan Sponsor with no portion coming from the insured member. Plans with this method of payment typically obligate the Plan Sponsor to enroll and pay the premium of all eligible members.

This is an alternative to standard Coordination of Benefits (COB). When a policyholder elects integration of benefits, it frequently results in less than 100% coverage. No benefit credit is established when benefits are integrated. When the secondary policy’s normal benefit is equal to or less than the primary policy’s payment, no payment will be made by the secondary policy. When the secondary policy’s normal benefit is higher than the primary policy’s payment, the secondary policy will pay the difference between its normal benefit and the primary policy’s payment.

Any dentist or specialist who does not have a contractual agreement with the dental benefit program. “Participating” means participating in a contractual arrangement rather than participating in the filing of insurance claims. Dentists and specialists may file claims and work with insurance carriers and yet be non-participating dentists. Out-of-network benefits apply when visiting a non-participating dentist or specialist. Out-of-network is sometimes referred to as out-of-panel.

Materials developed for use in all types of restorative procedures that are less costly than gold and other precious metals. a less expensive restorative material than gold or precious metals used in crowns.

Term used to denote the chewing surfaces of the bicuspids and molars.

See Bite Guard and Bruxism.

The grinding, chewing, or masticating surface of molars and Bicuspids.

The arrangement of “the bite”. The quality or condition of the fit, alignment, and positioning of the teeth in relation to the teeth of the opposing arch.

A cast restoration that covers the entire incisal or occlusal surface of the tooth. Similar to a crown/cap in materials used.

The period of time preceding the effective or anniversary date of a group insurance policy that allows eligible members to participate or not participate. A true Open Enrollment typically does not require evidence of insurability or impose Late Entrant restrictions even if the member was previously eligible in a prior year. Open Enrollment differs from Annual Enrollment and the term “Open Enrollment” is frequently misused. questions about enrollment and Late Entrant provisions should be addressed with the Benefit Administrator.

The branch of dentistry concerned with operative procedures in and about the mouth and jaws. The procedures typically require cutting into the gum(s) and/or dentin.

The branch of dentistry concerned with the detection, prevention, and correction of abnormalities in the positioning of the teeth and in their relation to the jaws. While often purchased as a benefit package, the Dental and Orthodontic benefits are actually separate components. A group may opt not to purchase Orthodontic benefits with their Dental plan.

Surgical corrective or therapeutic treatment performed to remove diseased and defective bone tissue.

See Non-Participating Dentist.

The amount the insured member or patient must pay the dentist or specialist after taking into account payments received or expected from insurance benefits.

An alleviating measure; a measure that relieves but does not cure.

See Network Provider.

A film held outside the mouth that records larger areas than is possible with a smaller film. It provides one continuous view of the teeth and associate structure. It is taken with a swinging-arm unit that moves from one side of the arch to the other.

A prosthesis replacing one or more, but less than all, of the natural teeth and associated structures; may be removable or fixed, unilateral or bilateral.

Participating refers to a dentist’s or specialist’s participation in a contract. A participating dentist or specialist is one who has a contractual agreement with a dental benefit organization, such as an insurance company or employer, to render care to eligible members under certain defined conditions and often at discounted and/or contracted fees. Also known as network providers and PPO providers. (See participating Provider Organization)

A PPO is most commonly a network of providers (dentists and specialist) who have agreed contractually to provide covered services at reduced rates to eligible members. The insured member retains the freedom to choose his/her own provider subject to a potential impact on his/her benefits. Insured members may change providers at any time and do not need to select a primary provider. PPOs are also called networks and panels.

The specialty of children’s dentistry.

An association of dentists and other professionals for each state who evaluate the quality and effectiveness of dental care and professional services.

A film that records the entire tooth, including the apex of the root and some of the surrounding bony tissues.

The branch of dentistry dealing with the examination, diagnosis and treatment of gum diseases, which involve the tissue that surrounds and supports the teeth.

The teeth that replace the primary teeth by around age 14 – the “adult” teeth.

See Porcelain Fused to Metal.

The individual employee, union member, or participant who is enrolled in a group plan for himself or herself and/or family. Also called insured member.

Also called the Policyholder. The company, union, or authorized entity who obtains a group policy and in whose name the group master policy is issued.

A type of Benefit Period arranged by the Plan Sponsor that can begin on any date of the year. (See Benefit Period)

A statement of terms of the contract.

The calendar, policy, benefit or fiscal year on which the records of a plan are kept and/or benefits are paid. (See Benefit Period)

Also called the Plan Sponsor. The company, union, or authorized entity who obtains a group policy and in whose name the master policy is issued.

A prosthetic or fake tooth. The part of a fixed bridge that is suspended between abutments to replace a missing tooth.

A white or tooth-colored material. It fuses at high temperatures to form a hard substance that is much like enamel in appearance. Used for inlays, facings, crowns, pontics and denture teeth. Dental porcelain is a fused mixture that is glass-like and has some transparency.

A method used in making crowns and fixed bridge units. Fusing porcelain to the metal gives the artificial tooth a white or tooth-colored appearance.

A pre-formed prosthesis to cover the labial surface of an individual tooth. Most often used to improve aesthetics. Veneer laminates are frequently placed for aesthetic reasons; therefore, most plans do not cover them.

In restorative dentistry, a metal screw that extends into the root of a pulpless tooth to provide retention and support for the subsequent restoration, usually a crown.

A single cast unit that provides for the retention and restores lost underlying tooth structure. It is placed into the tooth, followed by the building up of the core base of the tooth, then a permanent restoration such as a crown.

All teeth located behind the cuspids; a tooth having an occlusal surface.

See Participating Provider Organization.

The word authorization denotes permission and it is not the position of traditional reimbursement insurance plans to issue permission in order for a patient to obtain treatment. However, the treatment a patient receives may or may not be covered by the plan. To learn what to expect in payment from an insurance plan, a Pretreatment Estimate is suggested. (See Pretreatment Estimate)

In dentistry, most often used in reference to the optional gold crowns and gold bridge units where the percentage of gold present is relatively high in comparison to semi-precious and non-precious metals. Gold is a type of precious metal.

See Pretreatment Estimate.

See Bicuspids.

The amount charged by an insurance carrier for coverage. With group coverage, a Plan Sponsor may or may not contribute toward this amount; therefore, questions about premium and the cost of insurance should be referred to the Plan Sponsor, not the insurance carrier.

See DHMO.

See Pretreatment Estimate.

Both the process of obtaining an insurance estimate and the statement resulting from that process. With the assistance of the dentist, a patient’s written treatment plan and anticipated expenses are submitted to the insurance carrier along with supporting diagnostic information such as x-ray films, charting, and narrative explanations. The insurance carrier evaluates the treatment plan and responds with an explanation of the coverage that can be expected, subject to policy limitations that are noted and the patient’s eligibility at the time of services. pretreatment Estimates are the best way for patients to determine their anticipated Out-of-Pocket Expense. Pretreatment Estimates, sometimes called predeterminations and Prestatements, are offered as a service to insured members and dentists/specialists but are not a requirement.

A category of coverage for oral procedures. The other categories are Basic and Major. Each category may have a different coinsurance or deductible applied. See your Certificate Booklet to find out which procedures fall under which category.

The first teeth to erupt in childhood. Also called the “baby teeth.”

Determining whether a procedure has a benefit defined under the terms of the group contract, subject to plan provisions. eligible does not mean a procedure will receive payment, rather that there are circumstances where the procedure may receive a payment. An ineligible procedure does not qualify for coverage under the group contract that was chosen. Most plans specifically list all the eligible procedures — a procedure not listed will receive no payment.

Categories of covered procedures that may determine coinsurance levels and deductibles. The categories are Preventive, basic, and Major. See your Certificate Booklet to find out which procedures fall under which category.

Prevention of disease by removal of calculus, stains, and other extraneous materials from the teeth; the “routine” cleaning of the teeth by a dentist or dental hygienist.

Any professional who performs health, dental, and eye care services for an insured member. In dental insurance, refers to dentists and specialists (endodontists, periodontists, orthodontists, etc.)

A department within some insurance organizations responsible for customer service relating to Participating Provider organizations (PPO). Provider Relations works to build the PPO network, service provider contract issues, and maintain and distribute current information on who participates in the PPO network. Provider Relations typically does not handle patient benefit and/or claims questions. (See Participating Provider Organization)

An artificial replacement for one or more natural teeth and/or associated structures. In dentistry, this generally includes procedures such as crowns, inlays, onlays, veneers, bridge work, partial dentures, dentures, and certain implant services.

In dentistry, the surgical and dental specialties concerned with the artificial replacement of missing or damaged teeth.

Dental pulp is the tissue that fills the pulp chamber and root canals. (See Tooth Diagram)

Removal of dental pulp near the crown or cap portion of the tooth.

One-half of each dental arch; one-fourth of the two dental arches. The quadrants are the upper right, upper left, lower right and lower left. Many periodontal procedures are performed and billed per quadrant. (See Tooth Number Chart)

The name of the department within a number of insurance organizations primarily responsible for replying to written concerns, appeals, and complaints. This department also tracks and monitors performance related to quality service and compliance with internal and external guidelines and regulations.

Replacement of the denture base material without changing the occlusal relations of the teeth; adding to the denture base to compensate for altered tissue.

See Denture Reline.

See Composite.

An amendment attached to a group contract that modifies, adds or deletes a benefit or limitation contained in the policy.

The anatomic part of a tooth that connects to the bone via ligaments. It contains the canal(s) for the tooth’s nerves and blood vessels. The root structure supports the tooth and contains parts necessary to maintain a tooth’s vitality.

Surgical removal of the root portion of the tooth. It is usually performed on a multi-rooted tooth to eliminate a root that cannot be treated.

The space within the root of a tooth containing nerves and blood vessels.

Treatment of a tooth having a damaged or diseased pulp. It is normally performed by completely removing the pulp, sterilizing the pulp chamber and root canals, and filling those spaces with a sealing material.

The smoothing of roughened root surfaces by the use of scalers and curettes. (See Scaling and Root Planing)

Removing calculus (tartar) and stains from the teeth with a scaler and other special instruments. (See Scaling and Root planing)

An often difficult and time consuming procedure performed as a treatment therapy for certain diagnosed stages of gum disease (periodontics). Charting, a recording of the patient’s measurements periodontal disease, is a standard of care with this procedure – a copy of the patient’s charting should be submitted with claims for Scaling and Root Planing.

An Allowance Method in which the member’s policy booklet lists the exact maximum dollar amount that may be reimbursed for each procedure. Often called a defined benefit or maximum covered expense (MCE) allowance. These scheduled amounts do not change unless the Benefit Administrator requests and purchases a plan change. The insured member is responsible for the difference between the scheduled plan allowance and the contracted amount (if PPO) or the dentist or specialist charges.

A method of preventing decay in the pits and fissures of a tooth by thoroughly cleaning the tooth and then applying a sealing agent. Most plans only allow benefits for this procedure on permanent molars.

A section of the tax code establishing rules for use of pretax dollars in conjunction with qualified health care premiums and money set aside to pay certain qualified health care and dependent care services. (See Cafeteria Plan)

The method of providing benefits in which Plan Sponsors do not purchase conventional insurance but rather elect to pay for the claims themselves, generally through the services of a Third Party Administrator (TPA) or even through a conventional insurance carrier. (See CSO)

Material developed for dental restorations that have a lesser amount of precious metals. They are also called “noble alloys” and contain more than 25% but less than 60% gold, palladium and platinum.

A provider may write “Signature on File” in the appropriate section of a claim form to indicate to the insurance company that the provider has obtained authorization from the member to receive insurance payments directly, usually on an ongoing basis. Generally, insurance carriers will pay the provider directly if “Signature on File” is indicated rather than requiring the provider to obtain a signature with each claim.

Now called Maximum Procedure Allowance (MPA).

A fixed or removable appliance placed to maintain space created by the premature loss of a tooth or teeth.

One who applies himself/herself to a special study or pursuit. In dentistry, this would be an endodontist, orthodontist, periodontist, oral surgeon, pedodonist, or prosthodontist.

Abbreviation for spouse.

Stabilization or immobilization of periodontally involved teeth. Splinting may be accomplished with acrylic resin bite-guards, orthodontic band splints, wire ligation, provisional splints, and fixed prostheses.

An acrylic partial, with or without wire clasps, that replaces one or more teeth. Stayplates are used as temporary replacements until a more permanent prosthesis is prepared. Also known as a flipper.

An attachment that is incorporated into a removable partial denture or fixed bridgework to relieve pressure on the abutment teeth.

An extra tooth. A tooth in excess of the regular or normal number, or a tooth in an atypical position in the dentition that has no clear connection to its actual number or position.

If a Plan Sponsor offered qualified similar dental coverage to their members prior to being effective with a new carrier, the new carrier may “take over” certain aspects of the prior coverage. The new carrier may adapt their existing underwriting guidelines in order to prevent a break in coverage for insured members and avoid loss of benefits previously available. Takeover usually applies to Initial Insureds only. Takeover does not guarantee the new plan will cover all situations that might have been covered had the group not switched insurance carriers. The price paid for the new plan and the arrangements made when establishing the new plan determine the benefits and limitations that carry forward.

The joint between the skull and the mandible. (See TMD/TMJ)

The date on which the insurance contract ends.

In relation to group dental or eye care, a claims payer responsible for administering a benefit plan without assuming any of the financial risk. Third Party Administrator also commonly refers to any of various organizations that provide services for Plan Sponsors in providing and servicing employee benefits. (See CSO and ASO)

Temporomandibular disorder (TMD), also called temporomandibular jaw or joint syndrome (TMJ), is a disorder of the joint connecting the lower jaw to the temporal bone at the side of the skull. bruxism, a clenching or grinding of the teeth, is a condition often associated with TMD. appliances that may protect teeth from bruxism are called bruxism appliances, Night Guards, bite guards, and occlusal guards. The underlying cause of bruxism and/or TMD is often emotional stress, anxiety, fatigue, or interference with a proper bite. Few dental plans cover the treatment of bruxism and TMD, nor damage resulting from the conditions, because the underlying cause is not dental decay. Coverage with one’s medical insurance should also be investigated. (See Bruxism)

See TMD/TMJ.

A type of plan design with incentives to see network providers, usually of a Participating Provider Organization (PPO). The incentives may be in the form of lower member coinsurance, lower deductible, and/or higher maximums applied to procedures performed at a network provider than if performed at an out-of-network provider.

A tooth that has not broken through the bone and/or gingival tissue.

Confined to one quadrant or one side of an arch.

Formerly UCR. An Allowance Method derived from fees reported to insurance carriers from dental offices nationwide. Each procedure is assigned an allowance based on a percentile for all reported expenses submitted for the same procedure within the ZIP code area. U&C is common among reimbursement plans that offer the freedom to choose your own dentist because it offers a relatively consistent way of paying a percentage of the fee submitted. Watch this quick MAC/U&C video for a simple explanation of how dental claims are paid with a U&C out-of-network claim allowance.

See Porcelain Laminate.

Under this type of group plan, the member can choose whether or not they want coverage. Also called a “contributory” plan because the insured member pays at least a portion of the premium.

See Eligibility Period.

Electromagnetic radiation is transmitted through an object and onto a piece of film that when developed may reveal diagnosable conditions not evident through other means.