Glossary
To find a definition, click on the first letter of the corresponding term.
A
crowns, onlays, or inlays. Sometimes referred to as a retainer.
composite filling material to the tooth surface.
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)
or tooth-whitening, composite restorations (white fillings), porcelain prosthetics and veneers.
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:
- Usual and Customary (U&C)
- Scheduled Allowances (SCU)
- Maximum Allowable Charge on PPO plan (MAC)
- Maximum Allowable Benefit (MAB)
- Maximum Procedure Allowance (MPA)
Please refer to your certificate booklet to see what Allowance Method design is used for your plan.
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
performed 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.
sockets containing each tooth root. (See Alveolus)
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 (alveolectomy) in conjunction with extractions to necessary reconstruction of the ridge in
preparation for dentures. (See Alveolus)
material. (See Composite versus Amalgam restorations)
eliminate a root that cannot be treated.
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)
Tooth Number Chart)
Tooth Diagram)
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.
in the overlying labial or buccal alveolar bone.
They include dental prostheses, splints, and orthodontic appliances.
are the maxilla (upper jaw) and mandible (lower jaw). (See
Tooth Number Chart)
signature line on a claim form authorizes payment directly to the doctor’s office.
services received. Also called a walk-out statement. Please refer to section #2 of the claim form for more
information.
B
from the insurance company and the dentist or specialist fees.
may have a different coinsurance or deductible applied. See your Certificate Booklet to find out which
procedures fall under which category.
with the insurance carrier(s).
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:
- Calendar Year – Jan 1 to Dec 31 of the same year.
- Policy Year – The calendar, policy, benefit or fiscal year on which the
records of a plan are kept and/or benefits are paid. - Plan Year – Usually set by the group’s effective date or a group’s fiscal year.
- Employee Year – Set by the employee/plan member’s effective date and
applies to a family. - Dependent Year – Set by each individual person’s effective date.
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.
Tooth Number Chart)
the same film.
(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 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)
Tooth Number Chart)
C
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.
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)
unless otherwise stated in policy, the limit applies to all payable procedures including routine exams and
cleanings. (See Calendar Year)
tissue.
retainers on just one side.
amount is paid to each general dentist proportionate to the number of members who have selected him/her as
their primary general dentist.
formation of secondary dentin. Calcium hydroxide is frequently used.
progressive disintegration of tooth structures – tooth decay. An irreversible disease.
statement signed by the beneficiary and treating dentist that services have been rendered. The completed
form serves as the basis for payment of benefits.
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)
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.
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.
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.
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.
eligible members.
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.
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.
plan options are applied.
tooth.
gingival curettage.
mouth. They are considered to be the keystones of the arch. Sometimes referred to as the canine teeth.
(See Tooth Number Chart)
D
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.
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.
- Annual Deductible Deducted yearly on the plan’s Benefit Period. The amount is
- 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.
remaining Individual Deductibles to be waived on the family. There may be variations.
the mouth.
portion with cementum. (See Tooth Diagram)
restorations. (See Specialist)
permanent teeth or a combination.
fitting denture.
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.
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.
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.
tooth. (See Tooth Number Chart)
into divisions. Divisions may be used to identify differences in benefits among the divisions or simply for
a group’s accounting purposes.
(indemnity) or prepaid dental benefit program.
E
dental plan. There may be a Late Entrant provision and/or an Elimination Period applicable, as well as
other plan provisions.
coverage. It may be necessary to fulfill the group’s eligibility period before becoming eligible. (See Procedure Eligibility)
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.
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)
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.
and protects the dentin.
tissue. A “root canal (therapy)” is an endodontic procedure.
stability in supporting the crown and surrounding tooth structure.
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.
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.
F
performed. This is the reimbursement system used by conventional indemnity insurers.
pontics held in place by one or more retainers or abutment teeth. (See Bridgework)
screws.
or specialist whether on the PPO network or not.
or the surgical removal of the lingual tissue (frenum) that attaches the tongue to the floor of the mouth
and the alveolar ridge.
Example: One cleaning every 6 months.
(bridge) to replace an extracted tooth or teeth. This coverage will be provided even if the teeth were lost
prior to being insured.
G
each arch.
creation of new gingival margin.
surgical contouring of the gingival tissues.
or other bad occlusal habits. (See Bruxism)
H
cleanings under the direction of a licensed dentist. The work is often limited to routine prophylaxis
cleaning.
I
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.
from erupting normally. The anatomical position of the tooth in relation to the surrounding features
determines the type of impaction.
alveolar bone to provide support.
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.
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.
lower arches. (See Tooth Number Chart)
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).
into place. Plans usually provide the Alternate Benefit of a filling
for an Inlay.
network. Also known as In-panel Benefits.
(Other terms used for insured member are: member, subscriber, employee, covered person, eligible person,
enrollee, beneficiary)
J
Also applicable to the upper (maxilla) arch or jaw and its supporting bone structure.
K
L
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.
under the policy. Lifetime maximums are a common feature among orthodontic policies.
periods, and late entrant provisions, which affect an individual’s or group’s coverage.
M
may have a different coinsurance or deductible applied. See your Certificate Booklet to find out which
procedures fall under which category.
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.
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.
as the surgical removal of impacted wisdom teeth.
general dentists of a PPO network would agree to accept in that area.
would agree to accept in that area.
or family in a specified Benefit Period, typically a calendar year.
dentists within a ZIP code area. The MPA is reviewed and updated periodically to reflect increasing
provider fees.
used for the member are: insured, insured member, subscriber, enrollee, and employee.
as employee contribution on employer-sponsored plans.
of amalgam restorations.
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)
prior to one’s effective date of coverage. There are many variations. (See Missing Tooth/Existing Space)
They are used for grinding. in normal dentition, the molar farthest back in each quadrant is a “wisdom
tooth.” (See Tooth Number Chart)
N
services on insured members under a managed care arrangement. Also called panel providers. (See Participating Provider Organization)
flat surface for unobstructed movement of the mandible. Also called occlusal guard, bite guard, and bruxism
appliance. (See Bruxism)
light state of general anesthesia. The patient remains conscious but less sensitive to pain. It is also
referred to as “laughing gas.”
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.
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.
“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.
other precious metals. a less expensive restorative material than gold or precious metals used in crowns.
O
teeth in relation to the teeth of the opposing arch.
in materials used.
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.
procedures typically require cutting into the gum(s) and/or dentin.
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.
payments received or expected from insurance benefits.
P
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.
be removable or fixed, unilateral or bilateral.
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)
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.
effectiveness of dental care and professional services.
tissues.
involve the tissue that surrounds and supports the teeth.
herself and/or family. Also called insured member.
whose name the group master policy is issued.
paid. (See Benefit Period)
whose name the master policy is issued.
missing tooth.
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.
tooth a white or tooth-colored appearance.
aesthetics. Veneer laminates are frequently placed for aesthetic reasons; therefore, most plans do not cover
them.
retention and support for the subsequent restoration, usually a crown.
placed into the tooth, followed by the building up of the core base of the tooth, then a permanent
restoration such as a crown.
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)
percentage of gold present is relatively high in comparison to semi-precious and non-precious metals. Gold
is a type of precious metal.
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.
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.
have a different coinsurance or deductible applied. See your Certificate Booklet to find out which
procedures fall under which category.
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.
Preventive, basic, and Major. See your Certificate Booklet to find out which procedures fall under which
category.
“routine” cleaning of the teeth by a dentist or dental hygienist.
insurance, refers to dentists and specialists (endodontists, periodontists, orthodontists, etc.)
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)
generally includes procedures such as crowns, inlays, onlays, veneers, bridge work, partial dentures,
dentures, and certain implant services.
damaged teeth.
Q
upper left, lower right and lower left. Many periodontal procedures are performed and billed per quadrant.
(See Tooth Number Chart)
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.
R
the denture base to compensate for altered tissue.
in the policy.
tooth’s nerves and blood vessels. The root structure supports the tooth and contains parts necessary to
maintain a tooth’s vitality.
eliminate a root that cannot be treated.
the pulp, sterilizing the pulp chamber and root canals, and filling those spaces with a sealing material.
S
Scaling and Root planing)
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.
that may be reimbursed for each procedure. Often called a defined benefit. 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.
applying a sealing agent. Most plans only allow benefits for this procedure on permanent molars.
health care premiums and money set aside to pay certain qualified health care and dependent care services.
(See Cafeteria Plan)
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)
called “noble alloys” and contain more than 25% but less than 60% gold, palladium and platinum.
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.
orthodontist, periodontist, oral surgeon, pedodonist, or prosthodontist.
acrylic resin bite-guards, orthodontic band splints, wire ligation, provisional splints, and fixed
prostheses.
temporary replacements until a more permanent prosthesis is prepared. Also known as a flipper.
pressure on the abutment teeth.
the dentition that has no clear connection to its actual number or position.
T
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.
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)
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)
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.
U
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.
V
“contributory” plan because the insured member pays at least a portion of the premium.
W
X
reveal diagnosable conditions not evident through other means.