Dental Insurance Terminology
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Abutment: The teeth on either side of a missing tooth. Abutments are the part of the bridge used to support the replacement of the missing teeth (pontics).
Allowable Charges: The maximum dollar amount on which benefit payment is based for each dental procedure.
Amalgam: Silver filling. Amalgams are usually placed on the back teeth (posterior teeth).
Anesthesia: Relieves the sensation of pain.
Anterior Teeth: The front teeth (incisors and cupids).
Arch: The upper or lower jaw.
Back Teeth: See Posterior Teeth
Beneficiary: A person who receives benefits under a dental benefit contract.
Benefit: The amount payable by a third party toward the cost of various covered dental services or the dental service or procedure covered by the plan.
Benefit Booklet: A booklet or pamphlet provided to the subscriber which contains a general explanation of the benefits and related provisions of the dental benefit program. Also known as a "Summary Plan Descriptions."
Bicuspid: The first and second bicuspids, those are the fourth and fifth teeth from the center of the mouth to the back of the mouth. These are the back teeth that are used for chewing, they only have two points (cusps).
Bitewing: X-ray that shows the upper and lower teeth's biting surfaces on the same film. This x-ray shows the portion of the teeth above the gumline.
Bridge: A fixed appliance (prosthesis) that replaces missing teeth. A bridge is a series of crowns (abutments and pontics).
Bruxism: Clenching or grinding of the teeth.
Calculus: The sticky film on your teeth (plaque) that has hardened. Also known as tartar.
Canal: The narrow chamber inside the root of the tooth that contains the nerve and blood vessels.
Canines: See cuspids .
Capitation: A capitation program is one in which a dentist or dentists contract with programs' sponsor or administrator to provide all or most of the dental services covered under the program to subscribers in return for payment on a per-capita basis.
Caries: Correct technical term for decay.
Certificate Holder: The person, usually the employee or responsible party, who represents the family unit covered by the dental benefit program; other family members are referred to as "dependents."
Cleaning: See prophylaxis.
Closed Panel: A closed panel dental benefit plan exists when patients eligible to receive benefits can receive them only if service are provided by dentists who have signed an agreement with the benefit plan to provide treatment to eligible patients. As a result of the dentist reimbursement methods characteristic of a closed panel plan, only a small percentage of practicing dentists in a given geographical area are typically contracted by the plan to provide dental services.
Complete Series: See Full Mouth X-rays .
Composite Filling: Tooth colored filling. Insurance companies usually only allow them on the front teeth (anterior teeth). When composites are done on the back teeth (posterior teeth) the insurance company usually pays them as an amalgam. Composites are also known as resin fillings.
Contract Dentist: A practitioner who contractually agrees to provide services under special terms, conditions and financial reimbursement arrangements.
Contract Fee Schedule Plan: A dental benefit plan in which participating dentists agree to accept a list of specific fees as the total fees for dental treatment provided.
Coverage: Benefits available to an individual covered under a dental benefit plan.
Covered Person: An individual who is eligible for benefits under a dental benefit program.
Covered Services: Services for which payment is provided under the terms of the dental benefit contract.
Crown: Full coverage for a tooth.When the tooth cannot be restored by a filling a crown is usually fabricated.
Curettage: Surgical scraping of bacteria from the soft tissue. This is a periodontal procedure and is usually performed one quadrant at a time. Procedure code 4220.
Cusps: The high points on the chewing surfaces of the back teeth (posterior teeth).
Cuspids: The third tooth from the center of the mouth to the back of the mouth. These are the front teeth that have one rounded or pointed edge used for biting. Also known as canines.
Deciduous Teeth : See Primary Teeth .
Dental Benefits Organization: Any organization offering a dental benefit plan. Also known as dental plan organization.
Dental Benefit Plan: Entitles covered individuals to specified dental services in return for a fixed, periodic payment made in advance of treatment. Such plans often include the use of deductibles. coinsurance, and/or maximums to control the cost of the program to the purchaser.
Dental Benefit Program: The specific dental benefit plan being offered to enrollees by the sponsor.
Dental Insurance: A plan that financially assists in the expense of treatment and care of dental disease and accidents to teeth.
Dental Prepayment: A method of financing the cost of dental services prior to their receipt.
Denture: A removable appliance (prosthesis) that replaces all of the teeth in either the upper or lower jaw.
Dependents: Generally spouse and children of covered individual, as defined by terms of the dental benefit contract.
Diagnostics: Procedures performed by the dentist to identify what's going on in the mouth. The most common procedures you will deal with are the exam and x-rays classifies as preventive.
Edentulous: All the teeth are missing in either the upper or lower arch.
Eligibility Date: The date an individual and/or dependents become eligible for benefits under a dental benefit contract. Often referred to as effective date.
Endo: See Endodontics .
Endodontics (Endo): The treatment of diseases or injuries that affect the root tip or nerve of the tooth. The most common procedure that you will deal with is a root canal.
Enrollee: Individual covered by a benefit plan.
Exclusions: Dental services not covered under a dental benefit program.
Expiration Date: 1) the date on which the dental benefit contract expires.
2) The date and individual cease to be eligible for benefits.
Fee-for-Service: A method of paying practitioners on a service-by-service rather than a salaried or capitated basis.
Fee Schedule: A list of the charges established or agreed to by a dentist for specific dental services.
Fluorides: Topical application of a gel or liquid that prevents decay.
F.M.X.: See Full Mouth X-rays .
Front Teeth: See Anterior Teeth .
Full Mouth x-rays (F.M.X.): X-rays showing all the teeth. Includes 14 periapicals and 2 or 4 bitewings. Also known as a complete series.
General Anesthesia: Relieves the sensation of pain on the whole body. General anesthesia renders you unconscious.
Gingiva: The gums.
Health Maintenance Organization (HMO): A legal entity that accepts responsibility and financial risk for providing specified services to a defined population during a defined period of time at a fixed price. An organized system of health care delivery that provides comprehensive care to enrollees through designated providers. Enrollees are generally assessed a monthly payment for health care services and may be required to remain in the program for a specified amount of time.
Impaction: An unerupted or partially erupted tooth that will not fully erupt because it is obstructed by another tooth, bone, or soft tissue.
Implant: A post that is implanted in the bone. A crown, bridge or denture is then placed over the implant
Incisors: The central and lateral incisor, those are the first and second teeth from the center of the mouth to the back of the mouth. These are the front teeth with the flat edges for biting.
Inlay: A laboratory processed restoration made of metal, acrylic or porcelain. This filling does not involve the high points of the tooth (cusps).
Indemnity Plan: A dental plan where a third-party payer provides payment of an amount for specific services, regardless of the actual charges made by the provider. Payment may be made either to enrollees or, by assignment, directly to dentists. Schedule of allowances, table of allowances, or reasonable and customary plans are examples of indemnity plans.
Insurer: An organization that bears the financial risk for the cost of defined categories or services for a defined group of beneficiaries.
Insured: Person covered by the program.
Liability: An obligation for a specified amount or action.
Limitations: Restrictive conditions stated in a dental benefit contract, such as age, length of time covered, and waiting periods, which affect an individual's or group's coverage. The contract may also exclude certain benefits or services, or it may limit the extent or conditions under which certain services are provided.
Local Anesthesia: Relieves the sensation of pain in a localized area.
Managed Care: Refers to a cost containment system that directs the utilization of health benefits by:
a. restricting the type, level and frequency of treatment;
b. limiting the access to care; and
c. controlling the level of reimbursement for services.
Mandible: The lower jaw.
Maxilla: The upper jaw.
Maximum Allowance: The maximum dollar amount a dental program will pay towards the cost of a dental service as specified in the program's contract provisions, e.g., UCR. Table of Allowances.
Maximum Benefit: The maximum dollar amount a program will pay toward the cost of dental care incurred by an individual or family in a specific period, usually a calendar year.
Maximum Fee Schedule: A compensation arrangement in which a participating dentist agrees to accept a prescribed sum as the total fee for one or more covered services.
Member: An individual enrolled in a dental benefit program.
Molars: The first, second and third molars, those are the sixth, seventh and eighth teeth from the center of the mouth to the back of the mouth. The back teeth with the large chewing surface on top. They have 4 points (cusps).
Necessary Treatment: A necessary dental procedure or service as determined by a dentist, to either establish or maintain a patient's oral health. Such determinations are based on the professional diagnostic judgment of the dentist, and the standards of care that prevail in the professional community.
Nightguard: A removable acrylic appliance to minimize the effects of grinding the teeth (bruxism) or joint problems (T.M.J.). Usually worn at night to prevent the grinding of teeth or relieve joint pain. Also known as an occlusal guard.
Noncontributory Program: A method of payment for group coverage in which all of the monthly premium for the program is paid by the sponsor.
Nonduplication of Benefits: This may apply if a subscriber is eligible for benefits under more than one plan. A dental benefit contract provision relieving the third-party payer of liability for cost of services if the services are covered under another program. Distinct from a coordination of benefits provision, because reimbursement would be limited to the greater level allowed by the two plans, rather than a total of 100% of the charges. Also referred to as "benefit-less-benefit" or "carve-out".
Nonparticipating Dentist: Any dentist who does not have a contractual agreement with a dental benefit organization to render dental care to members of dental benefit program.
Occlusal: The chewing surfaces of the back teeth.
Occlusal Guard: See Nightguard .
Onlay: A laboratory processed restoration made of metal, porcelain or acrylic that replaces one or more of the highest points of the tooth (cusps).
Open Enrollment: The annual period in which employees can select from a choice of benefit programs.
Oral Surgery (O.S.): Surgery of the mouth.
Ortho: See Orthodontics .
Orthodontics (Ortho): Straightening of the teeth.
O.S.: See Oral Surgery.
P.A.: Common dental language for a periapical. See Periapical .
Palate: Roof of the mouth.
Panorex: An x-ray taken outside of the mouth that shows all the teeth on one film.
Partial Denture: A removable appliance (prosthesis) that replaces some of the teeth in either the upper or lower jaw.
Participating Dentist: Any dentist who has a contractual agreement with a dental benefit organization to render care to eligible persons.
Pedo: See Pedodontics .
Pedodontics (Pedo): The treatment of children's teeth.
Periapical: An x-ray that shows the whole tooth (above and below the gumline). Also known as a single film or P.A.
Perio: See Periodontics .
Perio Charting: Measures the depth that the gums have detached from the side of the tooth forming a pocket (perio pocket).
Periodontal Maintenance: Cleaning of the teeth following periodontal treatment, includes perio charting. Procedure code 4910. Also known as a perio prophy or perio recall.
Periodontics (Perio): The treatment of diseases of the gum or bone (supporting structure).
Perio Pocket: The pocket that forms when the gums detach from the side of the tooth.
Perio Prophy: See Periodontal Maintenance .
Perio Recall: See Periodontal Maintenance .
Permanent First And Second Molars: The adult first and second molars, they are the sixth and seventh teeth from the center of the mouth to the back of the mouth. Does not include the third molar (wisdom tooth).
Permanent Molars: The adult first, second and third molars.
Permanent Dentition: See Permanent Teeth .
Permanent Teeth: The adult teeth. Also known as the permanent dentition.
Plaque: A sticky film on the teeth. If it is not removed by brushing it can harden into calculus.
Point of Service: arrangements in which patients with a managed care dental plan have the option of seeking treatment from an "out-of-network" provider. The reimbursement for the patient is usually based on a low table of allowances, with significantly reduced benefits than if the patient had selected an "in-network" provider.
Pontic: The part of a bridge that replaces the missing teeth.
Posterior Teeth: The back teeth (Bicuspids and molars).
Preauthorization: Statement by a third-party payer indicating that proposed treatment will be covered under the terms of the benefit contract.
Precertification: Confirmation by a third-party payer of a patient's eligibility for coverage under a dental benefit program.
Predetermination: An administrative procedure that may require the dentist to submit a treatment plan to the third party before treatment is begun. The third party usually returns the treatment plan indicating one or more of the following: patient's eligibility, guarantee of eligibility period, covered services, benefit amounts payable, application of appropriate deductibles, co-payment and/or maximum limitation. Under some programs. predetermination by the third party is required when covered charges are expected to exceed a certain amount, such as $200.
Pre-existing Conditions: Oral health condition of an enrollee which existed before his/her enrollment in a dental program.
Preferred Provider Organization (PPO): A formal agreement between a purchaser of a dental benefit program and a defined group of dentists for the delivery of dental services to a specific patient population, as an adjunct to a traditional plan, using discount fees for cost savings.
Premium: The amount charged by a dental benefit organization for coverage of a level of benefits for a specified time.
Prepaid Dental Plan: A method of financing the cost of dental care for a defined population, in advance of receipt of services.
Prevailing Fee: Term used by some dental benefit organizations to refer to the fee most commonly charged for a dental service in a given area.
Preventive: Procedure performed to prevent decay and gum disease. The procedures that Trojan classifies as preventive are the exam, x-rays and prophys. The exam and x-rays are also known as diagnostic procedures.
Preventive Dentistry: Refers to the procedures in dental practice and health programs which prevent the occurrence of oral diseases.
Primary Dentition: See Primary Teeth .
Primary Teeth: The baby teeth. Also known as the primary dentition. The baby teeth are replaced by the adult teeth (permanent teeth)
Prophy: See Prophylaxis .
Prophylaxis: Cleaning the teeth. Also known as a prophy.
Prosthodontics: A fixed or removable appliance to replace missing teeth. Example: bridges, dentures and partials. Sometimes single crowns are considered prosthetics.
Prosthetic Replacement: How old does the crown, bridge, partial or denture have to be before it can be replaced? They usually must be unserviceable also.
Prosthodontics: Dealing with the replacement of missing teeth.
Purchaser: Program sponsor, often employer or union, that contracts with the dental benefit organization to provide dental benefits to an enrolled population.
Quadrant: One of the four equal sections of the mouth. The upper right, upper left, lower right or the lower left.
Quality Assessment: The measure of the quality of care provided in a particular setting.
Quality Assurance: The assessment or measurement of the quality of care and the implementation of any necessary changes to either maintain or improve the quality of care rendered.
R.C.T.: See Root Canal Therapy .
Reasonable and Customary (R&C) Plan: A dental benefit plan that determines benefits based only on "Reasonable and Customary" fee criteria.
Reasonable Fees: The fee charged by a dentist for a specific dental procedure that has been modified by the nature and severity of the condition being treated and by any medical or dental complications or unusual circumstances, and therefore may differ from the dentist's "usual" fee or the benefit administrator's "customary" fee.
Reimbursement: Payment made by a third party to a beneficiary or to a dentist on behalf of the beneficiary, toward repayment of expenses incurred for a service covered by the contractual arrangement.
Resin Filling: See Composite Filling .
Restorative: Procedures performed to restore the missing part of the teeth. Some insurance companies only consider the fillings to be restorative, others consider the fillings, crowns, bridges and dentures to be restorative.
Root Canal Therapy (R.C.T.): The nerve of the tooth is removed from the canal inside the root and replaced with a filling material
Root Planing: Deep cleaning of the teeth to remove calculus below the gumline. This is not a prophylaxis. This is a periodontal procedure and is usually performed one quadrant at a time. Procedure code 4341.
Schedule of Allowances: A list of covered services with an assigned dollar amount that represents the total obligation of the plan with respect to payment for such services, but does not necessarily represent the dentist's full fee for that service.
Schedule of Benefits: A listing of the services for which payment will be made by a third-party payer, without specification of the amount to be paid.
Sealant: Clear application of acrylic placed over the biting surface of the tooth to prevent decay. Most insurance companies only allow these on permanent teeth.
Single Film: See Periapical.
Subscriber: The person, usually the employee, who represents the family unit in relation to the dental benefit program. This term is most commonly used by service corporation plans.
Surcharge: A stated dollar amount paid to the dentist by the beneficiary, in addition to other reimbursement received by third-party payer(s).
T.M.J.: See Temporomandibular Joint .
Table of Allowances: A list of covered services with an assigned dollar amount that represents the total obligation of the plan with respect to payment for such services, but does not necessarily represent the dentist's full fee for that service.
Tartar: See Calculus.
Temporomandibular Joint (T.M.J.): Temporo (temporal bone), mandibular (lower jaw). This is the connecting hinge between the lower jaw and base of the skull. Also known as T.M.J.. T.M.J. treatment is sometimes paid under medical.
Termination Date: 1) the date on which the dental benefit contract expires.
2) The date and individual cease to be eligible for benefits.
Third Party: The party to a dental benefit contract that may collect premiums, assume financial risk, pay claims, and/or provide other administrative services
Third Molar: See Wisdom Tooth .
Third-Party Administrator (TPA): Claims payer who assumes responsibility for administering health benefits plans without assuming any financial risk. Some commercial insurance carriers and Blue Cross/ Blue Shield plans also have TPA operations to accommodate self-funded employers seeking administrative services only (ASO) contracts.
Third-Party Payer: An organization other than the patient (first party) or health care provider (second party) involved in the financing of personal health services.
Usual, Customary and Reasonable (UCR) Plan: A dental benefit plan that determines benefits based on "Usual, Customary, and Reasonable: fee criteria.
Usual Fee: The fee that an individual dentist most frequently charges for a given dental service.
Utilization: 1) The extent to which the members of a covered group use a program over a stated period of time; specifically measured as a percentage determined by dividing the number of covered individuals who submitted one or more claims by the total number of covered individuals. 2) An expression of the number and types of services used by the members of a covered group over a specified period of time.
Virgin Teeth: Teeth that have no decay or fillings.
Waiting Period: The period between employment or enrollment in a dental program and the date when a covered person becomes eligible for benefits.
Wisdom Tooth: The third molar, this is the eighth tooth from the center of mouth to the back of the mouth. Wisdom teeth are often impacted (obstructed from erupting) and have to be extracted.
*The source for this alphabetical list of dental terms is Trojan Professional Services, Inc. of Southern California and the American Dental Association (ADA).
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