- account/group
Term used to describe a dental benefit customer or purchaser, usually an employer or a union/labor trust. back to top
- adjudication
Processing a claim through a series of edits to determine proper payment. Auto-adjudication is processing a claim without any human interaction. back to top
- administrative costs
The costs assumed by a managed care plan for administrative services such as claims processing, billing and overhead costs. back to top
- administrative services only (ASO)/administrative services contract (ASC)
ASO or ASC refers to a program in which Delta Dental provides claims processing, eligibility, etc., but does not assume the underwriting risk. The purchaser pays the cost of paid claims plus an administrative charge. Also known as self-funded. ASO is the preferred term, but either is acceptable. back to top
- AHIP (America’s Health Insurance Plan)
A health insurance trade association whose members offer medical expense insurance, long-term care insurance, disability income insurance, dental insurance, supplemental insurance, stop-loss insurance and reinsurance to consumers, employers and public purchasers. back to top
- allowable charge
The fees, on which program deductibles, maximums and coinsurance percentage is based, that a dental program will reimburse a dentist for a service as defined by contract. This is the amount that can be charged back to patients. This is also referred to as the maximum plan allowance or maximum allowable charge. Dentists have agreed to accept a maximum plan allowance based on the agreements they have signed with Delta Dental. This does not apply to non-participating dentists. back to top
- allowable costs
Items or elements of an institution’s costs that are reimbursable under a payment formula. Allowable costs may exclude, for example, non-covered services, luxury accommodations, costs that are not reasonable and expenditures that are unnecessary. back to top
- alternate I.D.
Assigned identification number created to replace use of social security numbers for identification of enrollees. back to top
- American Dental Association (ADA)
A professional association of dentists in the United States that are committed to the public’s oral health, ethics, science and professional advancement. back to top
- approved amount
The total fee that must be paid by the member company and the patient. Participating dentists have agreed to accept a maximum plan allowance based on agreements signed with Delta Dental. Non-participating dentists use the submitted amount. back to top
- ASCII
American Standard Code for Information Interchange. It is the data representation code most commonly used on PCs, minicomputers and sometimes on mainframes. Standard ASCII uses 7 bits to represent 128 characters, which is sufficient to represent upper and lower case letters of the English alphabet, a variety of symbols and numbers, ASCII data files can be easily imported into Microsoft applications such as Access or Excel to produce dentist directories and mailing labels. back to top
- balance billing
Balance billing occurs when a participating dentist bills an enrollee for amounts disallowed by Delta Dental that are also not allowed to be charged to the enrollee. Participating dentists agree to accept the fee approved by Delta Dental as payment in full. Dentists may not bill an eligible Delta Dental patient for any difference or balance between the Delta Dental approved fee and the submitted fee. Out-of-network (non-participating) dentists are not limited in the amount they may balance bill. back to top
- basic procedures/basic benefits
In a standard dental benefit contract, basic procedures include restorations (fillings, etc.), oral surgery (extractions), endodontics (root canals), periodontal treatment (root planning) and sealants. back to top
- beneficiary
A person who is eligible to receive insurance benefits. back to top
- benefit differential
A benefit differential is a term used to describe how payment is made for a covered service, depending on whether the dentist providing the service is a participating or a non-participating dentist. For example, Delta Dental may pay 80 percent for covered basic services provided by a participating dentist, whereas payment may be only 70 percent if the services are provided by an out-of-network dentist. back to top
- benefit levels
The extent or degree of service a person is entitled to receive based on his or her contract with a health plan or insurer. back to top
- benefit summary
An overview of an enrollee’s dental benefit program, usually including co-payment percentages, deductibles, maximums and non covered services, often used at open enrollments. Also referred to as “benefit highlights.” See summary plan description and evidence of coverage. back to top
- benefit year
The 12-month period to which each enrollee’s deductibles, maximums and other plan provision are applied. Start and end date may vary from those of a calendar year. back to top
- benefits package
Services an insurer, government agency, health plan or employer offers under the terms of a contract. back to top
- birthday rule
When a dependent child's parents both have dental coverage, this rule states that the "primary" program (the one which pays first) is the one covering the parent whose month and day of birth falls first in the calendar year. The birthday rule is the most common rule for determining primary vs. secondary coverage, but it may be superseded by a court order such as a divorce agreement. back to top
- broker/consultant/producer
A person who works with a Delta Dental account executive to sell and service a Delta Dental group or account. A benefits consultant is paid a fee by the purchaser, while a broker works on commission and is paid by the benefits plan. Producer is an acceptable general term to describe both. back to top
- cafeteria plan
A corporate benefits plan under which employees are permitted to choose among two or more options that allocates a certain amount – through points or dollars – that each enrollee can use toward medical, dental and other benefits. Also known as flexible or “flex” benefits or Section 125 programs (the legal clause that permits the programs). back to top
- CDT codes (Current Dental Terminology)
Under HIPAA, the American Dental Association’s CDT codes are the required standard for electronic dental claims. back to top
- claim/claim form
Information submitted by a dentist or enrollee to establish that services were provided to an enrollee, from which processing for payment to the dentist or enrollee is made. A dentist is responsible for the accuracy of all information on a claim form. Claim forms can be submitted to carriers on paper or electronically. back to top
- claims reimbursement
The amount paid to Delta Dental by a group with an administrative services only (ASO) contract. An ASO group insures its enrollees with its own funds, and must reimburse Delta Dental for claims that have been paid on its behalf. back to top
- claims review
The method by which an enrollee’s health care service claims are reviewed before reimbursement is made. back to top
- clearinghouse
A system that allows electronic claims submissions through a single source. back to top
- COBRA
The Consolidated Omnibus Budget Reconciliation Act is federal legislation that requires employers to offer continued health insurance coverage to employees and their dependents who have had their health insurance coverage terminated. It allows enrollees, spouses, and children to pay to continue their health benefits coverage for up to 18 months after their coverage is terminated(or up to 29 months if the individual is disabled). For example, a spouse who would lose eligibility after divorcing a covered employee could decide to pay his/her own premium to continue group health coverage. back to top
- coinsurance
The percentage of the costs of services paid by the patient. The coinsurance is usually about 20 percent of the cost of services after the deductible is paid. See copayment. back to top
- committee
A committee is a work group that deals with ongoing issues, such as financial oversight or compliance. back to top
- coordination of benefits (COB)
When a person is covered by more than one benefit plan (for example, a child who is covered by both parents’ programs), which is known as dual coverage, the two sets of benefits are coordinated so that no more than 100 percent of the total covered expense is paid. Non-duplication of benefits is a contract provision that further limits coverage. See dual coverage and non-duplication benefits. back to top
- copayment
The enrollee’s share of payment for a given service. The copayment is usually expressed as a percentage of the dentist’s fee, but can be expressed as the enrollee’s preset share of payment for a given service. See coinsurance. back to top
- cost containment/cost management
A strategy that aims to reduce health care costs and encourages cost-effective use of services. back to top
- cost sharing
Financing arrangement whereby the enrollee in a health plan must pay some of the costs to receive care. back to top
- cost shifting
Because of the escalating costs of health care, employers have traditionally paid for all or most of employee health care coverage. There is now an increasing amount of contributions that employees are expected to make towards their own coverage. back to top
- covered services
Services for which payment is provided under the terms of the dental benefit contract. back to top
- credentialing
Review of documentation pertaining to a dentist and his/her practice, including verification of licenses, specialty certification (if applicable), malpractice insurance, state and local licensing board actions, infection control procedures and Occupational Safety and Health Administration (OSHA) requirements. back to top
- DDS/DMD
DDS stands for doctor of dental surgery. DMD stands for doctor of dental medicine. back to top
- deductible
The total amount (usually expressed as an annual figure) enrollees must pay toward treatment before their health benefits are paid. The deductible plus the copayment and amount over the annual maximum are often referred to as the enrollee’s out-of-pocket costs. Under Delta Dental benefit plans, diagnostic and preventive services are often exempt from a deductible. back to top
- Delta Dental Premier®
Delta Dental Premier is one of our three contracted national network based programs. Participating dentists agree to adhere to Delta Dental processing policies and are prohibited from billing a patient above the pre-negotiated fee, accepting billing under these terms as payment in full. This results in savings to the group and enrollees that avoids merely shifting costs. The Delta Dental Premier program has the nation's largest dental network, with more than three out of every four of the country's dentists participating. Delta Dental Premier provides a level of enrollee protection that is unmatched. back to top
- DeltaVision®
DeltaVision is an affordable vision benefit plan offered in select Delta Dental markets. These plans typically include pre-negotiated pricing on professional eye exams, eyewear, contact lenses and laser vision correction. back to top
- dentist filed fees
A participating dentist’s submission of fees for procedures common to their practice and reported most frequently on dental claims. back to top
- dentist/provider
Dentist, rather than provider, is the preferred term. A provider could refer to a hygienist, x-ray technician, dental laboratory or other practitioner who provides certain dental services but lacks a license to practice dentistry. See also participating dentist. back to top
- Department of Health and Human Services (HHS)
A federal department that oversees the administration of HIPAA as well as other federally funded programs that provide services such as prenatal screening, immunization, child care, nutrition, exercise and long-term care regulation. back to top
- Department of Labor/U.S. Department of Labor (DOL)
A federal department that oversees issues relating to workplace safety and health, pensions and benefits plans, employment and other issues relating to the American workplace. See Occupational Health and Safety Administration (OSHA). back to top
- Department of Managed Health Care (DMHC)
As nonprofit specialized health care service plans, most Delta Dental member companies are governed by their state’s Department of Managed Health Care and are subject to the requirements and regulations set by this government agency. back to top
- DHMO
Dental Health Maintenance Organization. See HMO back to top
- diagnostic and preventative procedures
In the standard client contract, these procedures include oral examinations, cleanings, x-rays, fluoride treatment and space maintainers. back to top
- disallowance
A denial by a health care payer for portions of the claimed amount. Examples would include coordination of benefits, services that are not covered ,or amounts over the fee maximum. back to top
- dual coverage
When an enrollee has coverage under more than one benefit plan. The primary and secondary carriers coordinate the two plans so that the primary carrier pays its portion first and the secondary carrier may pay the remainder. See coordination of benefits and non-duplication benefits. back to top
- e-business
The abbreviation for electronic business. It means conducting business through electronic means, particularly via a computer network such as the Internet. back to top
- e-commerce
Conducting transactions online, especially buying and selling products. Online enrollment and renewal services are examples of e-commerce. back to top
- electronic data interchange (EDI)
This term applies to all computer-to-computer communications. For example, EDI occurs when a dental office’s computer transmits claim data to a clearinghouse’s computer for retrieval by the carrier’s computer. back to top
- emergency services
Dental services that are immediately required to relieve pain, swelling or bleeding, or required to avoid jeopardizing the patient’s health. back to top
- employee contribution
The portion of the insurance premium paid by the employee. back to top
- Employer Identification Number (EIN)
See Tax Identification Number. back to top
- endodontist
Dental specialist who treats the root and nerve of the tooth. back to top
- enrollee/subscriber
People who are covered under a Delta Dental plan. Subscribers are the persons actually counted in determining the rates for the group (generally employees or members of the group) and enrollees includes both subscribers and their covered dependents. back to top
- ERISA (Employee Retirement Income Security Act of 1974)
An American Federal Statute enacted in 1974 that establishes minimum standards for pension plans in private industry and provides for extensive rules on the federal income tax effects of transactions associated with employee benefit plans. Protects the interests of employee benefit plan participants and their beneficiaries by requiring the disclosure to them of financial and other information concerning the plan; by establishing standards of conduct for plan fiduciaries by providing for appropriate remedies and access to the federal courts. back to top
- evidence of coverage (EOC)
A booklet provided to enrollees that gives a detailed legal description of benefits covered under their plan. See summary plan description (SPD) and benefits summary. back to top
- exclusive provider organization (EPO)
A dental benefit plan design in which enrollees must have treatment provided by a dentist in their EPO network in order to receive benefits. If an out-of-network dentist provides treatment, the EPO will offer limited or no coverage for the visit. back to top
- explanation of benefits (EOB)
An industry term for the notice that enrollees receive after a claim is processed. The EOB provides information about the fees charged, what procedures were provided, and the enrollee’s payment portion. See Notice of Payment (NOP). back to top
- fee schedule
A comprehensive listing of fees used to reimburse providers on a fee-for-service basis. back to top
- fee-for-service
A plan design in which the dentist is reimbursed a specified amount per service. back to top
- filed fees/fee listing
Delta Dental’s unique system of determining fees for reimbursement purposes for the Delta Dental Premier network. back to top
- flexible benefit plan
A benefit program that offers employees a number of benefit options, allowing them to tailor benefits to their needs. See cafeteria plan. back to top
- general dentist
General dentists provide a full range of dental services for the entire family. back to top
- group/account
Term used to describe a dental benefit customer or purchaser, usually an employer or a union/labor trust. back to top
- Heath Insurance Portability and Accountability Act of 1996 (HIPAA)
This federal initiative becomes effective in stages over several years. Title I of HIPAA was enacted to ensure that people can keep their health insurance when changing jobs. Title II of HIPAA requires adherence to coding and transmission standards for electronic health care transactions as well as to privacy and security requirements to protect health care information and anti-fraud measures. See the Administrative Simplification section of the Department of Health and Human Services’ web site for more information at http://aspe.os.dhhs.gove/admnsimp/. back to top
- HMO (health maintenance organization)
A method of health care delivery in which enrollees receive all treatment from the medical or dental office in which they are enrolled. The physician or dentist receives a single monthly payment from the benefits carrier for each enrolled patient, no matter how many services that patient receives. This type of benefit is also called capitation. See DeltaCare. back to top
- in-network
See network. back to top
- limitations/exclusions
Services that are limited or excluded from a dental benefit plan. The enrollee is usually responsible for the fee for services that are not benefits of the dental benefit plan. These services are called optional services. back to top
- managed care
Can refer to any health care program that features cost containment mechanisms, such as placing restrictions on the type or frequency of treatment, limited access to dental care or allowing up to a maximum fee for covered services. All of Delta Dental’s programs, including fee-for-service programs, contain aspects of managed care. back to top
- maximum fee schedule/maximum allowable reimbursement
A compensation agreement in which a participating dentist agrees to accept a set amount as the total fee for one or more covered services. back to top
- maximum/ annual maximum/maximum benefit
The maximum payment Delta Dental will make within a given time period. Some plans have no maximum. Some maximums apply to the lifetime of the benefit plan; others apply to a particular time period (calendar year, benefit year, etc.) or to particular services (such as a separate maximum for orthodontic benefits). back to top
- Medicaid
A federal-state program that helps pay for health care for the needy, aged, blind and disabled, and for low-income families with children. A state determines eligibility and which health services are covered. The federal government reimburses a percentage of the state’s expenditures. back to top
- Medicare
A federal health care insurance program for people aged 65 and over, and for the disabled. Eligibility is based mainly on eligibility for Social Security. Medicare helps pay charges for hospitalization, for stays in skilled nursing facilities, for physician’s charges and for some associated health costs. There are limitations on the length of stay and type of care. back to top
- National Association of Dental Plans (NADP)
A trade association that promotes and advances the HMO and PPO sector of the dental benefits industry to improve consumer access to affordable, quality dental care. back to top
- National Association of Insurance Commissioners (NAIC)
Assists state insurance regulators, individually and collectively, in serving the public interest and achieving fundamental insurance regulatory goals. back to top
- National Provider Identifier (NPI)
HIPAA mandated standard provider identifier in electronic claims processing. All providers were required to have an NPI by May 23, 2007. back to top
- network/panel
Both words refer to the dentists who have agreed to provide treatment within certain administrative guidelines for certain programs (participating dentists). back to top
- non-duplication of benefits
In dual coverage cases, some customers have a non-duplication of benefits contract provision. This term describes the way the secondary carrier calculates its portion of the payment. The secondary carrier calculates what it would have paid if it were the primary plan and subtracts what the other plan paid. If the primary payment was greater than or equal to what the secondary coverage would have paid, the secondary program will make no payment. See dual coverage. back to top
- non-participating
Any dentist who does not have a contractual agreement with Delta Dental to provide dental services to enrollees of a Delta Dental benefit plan. See participating. back to top
- Notice of Payment or Notification of Payment (NOP)
The notice enrollees receive after a claim is processed, detailing the procedures and fees submitted and the amount for which they are responsible. Also known in the industry as Explanation of Benefits (EOB) or Notification of Benefits (NOB). back to top
- Occupational Safety and Health Administration (OSHA)
A division of the U.S. Department of Labor, created in 1971. OSHA’s mission is to ensure safe and healthful workplaces in America and to protect workplaces in America and to protect workers by enforcing the nation’s labor laws. back to top
- oral pathologist
Dental specialist who diagnoses diseases of the mouth from the study of tissue samples. back to top
- oral surgeon
Dental specialist who removes impacted teeth and repairs fractures of the jaw and other damage to the bone structure around the mouth. back to top
- orthodontist
Dental specialist who straightens or moves misaligned teeth and/or jaws, usually with braces. back to top
- out-of-network
See network. back to top
- out-of-pocket costs
The portion of dental fees that the enrollee pays. Depending on the circumstances, it may include a copayment, a deductible, and any amount exceeding the plan’s maximum and optional services not covered by the plan. As long as the treatment is provided by a Delta Dental participating dentist, out-of-pocket costs do not include the difference between the approved fee and the fee submitted. That difference is absorbed by the dental office, not the enrollee or the plan – a key difference between Delta Dental and other carriers. See guaranteed copayments, balance billing and limitations/exclusions. back to top
- overbilling
The term for overstating the dentist’s true fees in order to collect more money from dental carriers. The most common form of overbilling is when a dentist waives patient copayments, thus overstating the amount he/she actually charges and intends to collect. back to top
- participating dentist/Delta Dental dentist
These words refer to dentists who contract with Delta Dental and abide by certain administrative guidelines, such as charging Delta Dental enrollees no more than the pre-approved fees. back to top
- payment differential
A term used to describe how payment for a service is calculated when the dentist is participating or non-participating. back to top
- pediatric dentist
Dental specialist who generally limits treatment to children and teenagers. back to top
- performance guarantee
A contractual arrangement Delta Dental has with some customers to provide specific levels of service, claims processing and/or reporting. Financial penalties are imposed on Delta Dental for non-attainment and incentives may be awarded for attainment. back to top
- periodontist
Dental specialist who treats gums, tissue and bone that support the teeth. back to top
- point of service (POS)
A dental benefits plan that allows enrollees that opportunity to select a participating network dentist or a non-participating network dentist. back to top
- preauthorization
Provided upon the request of dentists, a preauthorization gives the guaranteed amount of how much a proposed treatment plan will be covered under a patient’s dental program and what the patient’s out-of-pocket cost will be. The difference between a preauthorization and a predetermination is that with a preauthorization, the amount Delta Dental will pay is guaranteed as long as the preauthorized services are provided within the preauthorized period (usually 60 days). back to top
- predetermination (pre-d)/precertification
Provided upon the request of dentists, a predetermination gives an estimate of how much of a proposed treatment plan will be covered under an enrollee’s dental program and what the enrollee’s out-of-pocket cost will be. Predeterminations generally apply to fee-for-service plans, not prepaid plans. back to top
- pre-existing
One word, with a hyphen. An example of a pre-existing condition is a tooth that was missing before the enrollee had coverage. Standard contracts do not exclude benefits for restoration of pre-existing conditions. back to top
- preferred provider organization (PPO)
A PPO is a fee-for-service program that allows enrollees to choose any dentist but provides financial incentives to choose lower-priced dentists who are part of the PPO network. back to top
- prefiled fees
Delta Dental’s unique system of determining fees for reimbursement purposes for the Delta Dental Premier network. back to top
- premium
The monthly payment customers make to Delta Dental for fully insured plans. back to top
- prevailing fee
Allowable amount for procedures performed by a non-participating dentist. back to top
- preventive/preventative
Preventive is the preferred word to describe services such as cleanings and fluoride treatments to prevent decay. back to top
- primary enrollee/primary subscriber
See enrollee. back to top
- producer
See broker back to top
- professional review
carriers’ review of dentists’ utilization records. back to top
- program
See plan. back to top
- prosthodontist
Dental specialist who replaces missing teeth with artificial materials, such as a bridge or denture. back to top
- provider
Dentist is the preferred term, unless referring to other practitioners as well, such as dental hygienists. back to top
- rate
Term that refers to a customer’s premiums or fees. back to top
- request for information (RFI)
Issued by a customer, typically a governmental agency that wants to get an idea of whether there will be adequate competition if an RFP (request for proposal) is released, or to gain a better understanding of current industry standards, practices and product availability related to its specific program needs. back to top
- request for proposal (RFP)
A request by a prospective customer for a proposal based on the customer’s program needs. back to top
- self-funded/self-insured
A customer that funds its own claims. See administrative services only / administrative services contract. back to top
- special investigative unit (SIU)
A company department or unit required under law by many states that is responsible for conducting fraud investigations and overseeing anti-fraud education efforts. back to top
- specialist
A dentist who has received advanced training and is certified in one of the recognized dental specialties: endodontics, orthodontics, oral surgery, pediatric dentistry, periodontics and prosthodontics. back to top
- subscriber/enrollee
These words apply to people who are covered under a Delta Dental plan. Subscribers are the persons actually counted in determining the rates for the group (generally employees or members of the group) and enrollees includes both subscribers and their covered dependents. back to top
- summary plan description (SPD)
An enrollee booklet for members of an ERISA plan, similar to an evidence of coverage (EOC) or a benefit summary. back to top
- Tax Identification Number (TIN)
All dentists (as well as vendors, employees and others we do business with) must have a TIN on file for tax reporting purposes. The TIN can be a social security number or an employer identification number (EIN). back to top
- underutilization/overutilization
Terms to describe usage patterns below or above normally expected ranges. back to top
- utilization
The number of enrollees using a plan in a given period of time. The term also refers to the pattern of treatment received or provided by a particular dentist, patient or customer. back to top
- work in progress
The term “work in progress” (also referred to as work in process) is used to describe a situation in which dental work was begun while an enrollee was eligible, but eligibility was lost while the dental work was “in progress.” It can also mean dental work that was begun while the enrollee was eligible under one plan, but is completed when the enrollee is covered under a different plan. Except for orthodontic treatment, work in progress is usually the responsibility of the plan that is in force when the work was started. See orthodontic takeover. back to top
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Below is a glossary listing of common dental benefit terms. Select the link of the word you want defined. 