The dollar amount a dentist agrees to accept as full payment for a procedure from both the insurance company and the patient.
The steps involved in processing a claim.
The most money a dental plan will pay for care within a benefit period. Once you reach the maximum amount, you pay any costs for the remainder of the benefit period.
A formal request to have a denied or unpaid claim reviewed by Delta Dental. This request can be made by the member or the dentist.
assignment of benefits
When a patient requests Delta Dental pay the dentist directly.
The process by which Delta Dental determines whether a procedure or treatment is a referable benefit under the member’s plan.
The person who files a claim for payment. This can be the dentist, the member or another person.
When a dentist bills a member for amounts above Delta Dental's payment and the member's coinsurance amount (this total is the accepted fee). Contracted dentists agree to Delta Dental's accepted fee as full payment and will not balance bill for covered services. Out-of-network (non-contracted) dentists are not limited in the amount they may charge the member, and thus may balance bill.
Dental services provided under the terms of the contract as specified in the description of benefits and copayments. Usually includes restorations (fillings), oral surgery (extractions), endodontics (root canals), periodontal treatment (root planing) and sealants.
The person eligible for benefits under a plan; also known as the insured or the member.
The difference in the percentage level of benefits provided based on whether the dentist is a contracted or non-contracted dentist. (For example: 50% coverage when visiting a contracted dentist vs. 40% for a non-contracted dentist.)
The amount of time (usually 12 months) during which your plan is active. This is not always a calendar year.
benefit waiting period
The 12-month period of continuous enrollment that a member must complete before certain dental procedures become covered benefits.
The amounts your Delta Dental plan pays for covered dental services.
Payments made to general dentists who participate in a closed network dental plan.
The period beginning on Jan.1 and ending on Dec. 31.
The company that administers dental plans.
Centers for Medicare & Medicaid Services (CMS)
The federal agency responsible for administering Medicare, Medicaid and other programs. It is part of the U.S. Department of Health and Human Services.
claim/claim form/treatment form
An itemized statement usually submitted electronically by a dentist requesting payment for services from Delta Dental. Sometimes, a member visiting a non-Delta Dental dentist may need to submit a claim. A claim form is also used to request a pre-treatment estimate.
A dental plan that requires patients to get their care from a dentist in that plan’s network. A dental HMO is an example of a closed panel plan.
A type of coverage where the member pays a percentage of the cost for a procedure. For example, if the plan’s allowed amount for an office visit is $100 and the coinsurance is 20% (based on a benefit level of 80%), then the member pays 20% of $100, or $20.
COBRA (Consolidated Omnibus Budget Reconciliation Act)
Federal legislation requiring continuing insurance coverage for employees and/or dependents due to an event like a job loss.
A discussion between a dentist and patient to review the patient's dental needs and proposed treatment.
The agreement between Delta Dental and contractholder, including the application for the contract, the attached schedules, and any appendices, endorsements or riders. The contract constitutes the entire agreement between the parties.
A dentist who has a contract with Delta Dental; also known as a participating or network dentist.
The dollar amount a contracted dentist has agreed to accept as full payment for a service.
coordination of benefits
When you are covered by more than one dental plan, the dental carriers follow a process to determine the order of payment and the amount each will pay. (Example: A child who is covered by both parents’ plans.)
The fixed dollar amounts a member is responsible for when receiving treatment, usually in DHMO-type plans.
The share of expenses that a member must pay, including any deductibles, copayments/coinsurance and amounts over the annual or lifetime maximum.
Current Dental Terminology
A listing of dental procedure codes copyrighted and published by the American Dental Association.
Like car insurance, this is the amount you must pay before your benefit plan begins to pay for your dental treatment. If you have a spouse and dependents enrolled in your plan, you may be subject to a family deductible instead of an individual deductible.
DeltaCare USA dentist
A dentist who is member of the DeltaCare USA network.
Delta Dental dentist
A dentist who is a member of the Delta Dental PPO and Delta Dental Premier networks.
dental provider organization (DPO)
A Delta Dental Insurance Company fee-for-service plan offered only in Texas. This plan uses the Delta Dental PPO™ dentist network.
A duly licensed dentist legally entitled to practice dentistry at the time and in the state or jurisdiction in which services are performed.
diagnostic and preventive services
A category of dental services that include benefits for oral evaluations, routine cleanings, x-rays and fluoride treatments. These are usually covered at the highest benefit level to encourage you to seek regular care and prevent problems from developing.
dual choice/dual option
When you are offered a choice between two or more dental plans from your employer.
When you are covered by more than one dental benefits plan. Example: When you are covered by your spouse’s plan as well as your own.
The date a dental benefits contract becomes active (effective). Also, the date a member becomes eligible for benefits.
Requirements that define who and when a person may qualify to enroll in a plan.
Any of the dependents of a member who are eligible to enroll for benefits and who meet the conditions of eligibility as described under eligibility for benefits.
When you are enrolled in a plan and can use the benefits as of the effective date.
Dental services that are immediately required to relieve pain, swelling or bleeding, or are required to avoid jeopardizing the patient’s health.
Dental services that involve treatment of diseases or injuries that affect the root tip or nerve of the tooth.
exclusive provider organization (EPO) plan
A type of plan that requires members to visit network dentists to receive coverage.
The date an individual is no longer eligible for his or her benefits.
Explanation of Benefits (EOB)
The notice that members and dentists receive after services have been provided and a claim processed. The EOB provides information about the fees charged, what procedures were provided, any adjustments made by the carrier and the member’s coinsurance payment.
A plan where the dentist is paid a specified amount per service and the member is responsible for any applicable deductible, coinsurance and amounts over the annual maximum.
When an employer offers multiple benefit plans to choose from, i.e., a “menu” of plans; also known as a cafeteria plan.
flexible dual choice
An option that allows a member to switch between two dental plans selected by the employer, as often as monthly, removing the restriction of changing plans only during open enrollment.
freedom of choice
A plan feature that allows members to visit any licensed dentist (usually a fee-for-service plan).
A student who is regularly attending an accredited school with an academic schedule of at least 12 credits.
A written or verbal statement of dissatisfaction by a member. Delta Dental follows regulatory requirements in responding to grievances.
health care exchange
A government-regulated marketplace of insurance plans offered to individuals or small businesses who lack health care.
HIPAA (Health Insurance Portability and Accountability Act)
A federal initiative with a focus on patient privacy and allowing people to keep their health insurance even when changing jobs.
health maintenance organization (HMO)
A health care option where members receive most or all of their treatment from a primary care medical or dental office to which they are assigned. The primary care dentist may refer a member to a specialist when needed. A dental HMO may be be abbreviated as DHMO.
Services provided in a plan either by a contracted or non-contracted dentist.
Depending on the plan, benefit levels could differ depending on whether the member visits an in-network or out-of-network dentist.
The eligible member (primary member).
least expensive alternative treatment
When there are multiple treatment options for a specific condition and the dental plan pays for the least expensive treatment.
The total dollar amount a plan will pay for a specific dental service for the life of the member or the plan.
limitations and exclusions
Limitations are usually related to a specific time or frequency — for example, a plan may cover only two cleanings in a 12-month period or one cleaning every six months. Exclusions are services not covered by a plan.
A category of services that include procedures such as crowns, dentures and implants.
maximum contract allowance
The amount on which Delta Dental bases its payment (for example, a benefit level of 80% would be 80% of the contract allowance). Depending on the contract with the purchaser, the allowance may be the same as the accepted fee, a PPO fee, a table of allowance fee or some other amount.
Medicaid and Medicare
Medicare and Medicaid are two government-sponsored programs designed to help cover health care costs.
People can be eligible for both Medicare and Medicaid.
A person enrolled in a dental plan; also known as subscriber, beneficiary or insured.
A group of contracted dentists who agree to certain fees and other contractual requirements.
Non-Delta Dental dentist/non-participating dentist
A dentist who does not contract with Delta Dental and who is not contractually bound to abide by Delta Dental’s administrative guidelines.
A plan that allows members to visit the dentist of their choice, including specialists, without having to get a referral from a primary care dentist or the dental carrier.
The time when people can enroll in, change or cancel dental coverage.
open network plan
A plan where members can visit any licensed dentist and can change dentists at any time without contacting Delta Dental.
An out-of-network dentist is a dentist who does not have a network contract with Delta Dental. For a given plan, an out-of-network dentist refers to a dentist who is not bound by a Delta Dental contract to follow specific fee requirements when treating patients covered under applicable plans.
Any amount the member is responsible for paying, such as any deductible, copayment or coinsurance, amount over the annual or lifetime maximum and for non-covered services.
Any dentist who contracts with Delta Dental.
The portion of a dentist’s fee that a member pays for covered services. See “out-of-pocket costs.”
preferred provider organization (PPO)
An open network, fee-for-service plan that allows members to visit any licensed dentist but usually has lower costs and may have increased benefits when visiting a network dentist.
The amount a member pays for coverage. This amount can be taken out of a paycheck on a recurring basis or paid in full in advance of the benefit year.
A dental HMO plan featuring set copayments, no annual deductibles and no maximum limits for covered services.
Requested by a dentist on behalf of a patient, this provides the member with an estimate of coverage and out-of-pocket costs for a proposed treatment plan.
The person who has the coverage through his or her employer or who is responsible for plan payments; also known as member. A spouse or dependent children may be covered under the primary member’s plan.
The number given to a dental procedure as defined by the American Dental Association. These codes are standardized and used throughout the dental industry.
Any licensed dentist (including general dentists and specialists) who performs dental services for a member. This person can also be a dental hygienist, X-ray technician or other practitioner who provides dental services.
Technical term for an X-ray.
special health care need
A physical or mental impairment, limitation, or condition that substantially interferes with a member’s ability to obtain benefits. Examples include the inability to obtain access to the assigned contract dentist’s facility because of a physical disability and the inability to comply with the contract dentist’s instructions during examination or treatment because of physical disability or mental incapacity.
Services performed by a dental specialist, such as oral surgery, endodontics, periodontics, or pediatric dentistry. For certain plans, specialist services must be preauthorized in writing by Delta Dental.
A partner of the primary member by marriage, civil partnership or domestic partnership. To receive treatment, the person may have defined as a spouse by the laws of the state where the contract is issued and delivered or where the primary member resides.
The amount billed by a dentist for a specific procedure.
summary plan description
A document that explains benefits and provisions of the dental plan; also known as a benefit booklet.
table of allowances
A plan that provides a list of covered services and the maximum amount a plan will pay for each procedure. Members pay the difference between the amount the dentist charges and what the plan pays.
unbundling of procedures
To break down a procedure into several component parts. By charging a separate fee for each component, the overall fee for the procedure might be higher, resulting in increased cost to the member. Contracted dentists agree they will not unbundle procedures when billing.
A plan where members can sign up for coverage and pay most or all the cost. It’s also known as an employee-funded plan.
The amount of time a person must be enrolled in a plan before being eligible for certain benefits.
Benefits paid to an employee who experiences a work-related injury or illness.
Wear on a tooth by brushing too hard and/or holding things with the teeth.
An infection of a tooth, soft tissue or bone.
Material used to fill cavities in teeth. Dental amalgam is a mixture of silver, mercury and other metals.
Administered to patients to create temporary numbness in the mouth allowing for dental work to be done without feeling pain.
The teeth toward the front of the mouth, which include the incisors and cuspids.
The anatomic area at the end of the tooth root.
The surgical removal of the apical portion of the tooth through a surgical opening made in the overlying bone and gingival tissues. This procedure is often performed when an infection develops or persists after a root canal treatment.
Normal wearing down of a tooth’s surface from chewing.
The first set of teeth; also known as primary or deciduous teeth.
A metal ring placed around a tooth and secured with cement as part of orthodontic treatment.
The teeth with two rounded points located between the cuspids and molars; also known as premolars.
An x-ray of the area of the mouth where the back teeth touch each other; useful in spotting early stages of tooth decay.
A technique to lighten the color of heavily stained teeth. Considered a cosmetic procedure.
The technique to adhere a filling material to a tooth. Bonding materials may be used to repair chipped, cracked, misshapen, or discolored teeth or to fill in a gap between teeth.
Surgical procedure when bone is implanted in the jaw, usually in preparation for adding implants a few months later.
Non-removable artificial teeth attached to adjoining natural teeth when one or a few teeth are missing.
Involuntary clenching or grinding of the teeth, often during sleep.
A term referring to the inside of the cheeks.
burning mouth syndrome
Ongoing or recurring burning feeling in the mouth without an obvious cause.
Deposit of minerals coated with bacterial plaque that builds up on teeth; also known as tartar.
A mouth sore that appears white with a red halo; usually lasts 10-14 days.
Breakdown of tooth structure due to acids produced by bacteria; also known as cavities or tooth decay.
A procedure that uses a model of the tooth to cast a restoration such as a crown, inlay or onlay to replace lost tooth structure.
Breakdown of tooth structure due to acids produced by bacteria; also known as caries or tooth decay.
Soft tissue infection causing extensive hard swelling; a potentially dangerous condition that requires immediate attention.
Thin, hard tissue that covers the root of a tooth.
The four front teeth. The centrals are the two upper and two lower teeth in the center of the mouth. The laterals are the teeth adjacent to the centrals.
Hairline fractures that develop in tooth enamel, usually from normal wear and tear but also trauma; they do not affect the structural integrity of the tooth.
Hairline fractures that develop in tooth enamel, usually from normal wear and tear but also trauma; they do not affect the structural integrity of the tooth.
An artificial tooth-shaped covering made of metal, porcelain or porcelain fused to metal, used to restore teeth that have weakened from decay, are severely damaged or chipped.
The pointed or rounded part of a tooth’s biting surface.
The teeth near the front of the mouth that come to a single point. Also known as eye teeth or canines.
Primary or baby teeth.
Material used to clean between the teeth and around the gums.
The hard, dense and bony tissue forming the bulk of a tooth under the enamel.
Removable artificial teeth in a plastic base that rests directly on the gums. A denture may be a complete or partial depending on the number of missing natural teeth.
Pain and inflammation in a tooth socket after the tooth is removed, potentially leaving bone and nerve endings exposed
Hard, calcium-rich surface covering a tooth.
Dentist specializing in diseases of the tooth pulp, performing such services as root canals.
A plastic or porcelain surface placed on the front of a tooth or crown for a natural appearance.
Replacement of missing or damaged tooth structure with artificial materials; usually made of metals (a mix of silver, liquid mercury and other metals), resin (plastic) or porcelain.
Dentist who provides a full range of services for all age groups.
An inflammation of the gums surrounding the teeth caused by a buildup of plaque or food particles.
Bad breath resulting from oral or stomach issues.
A tooth blocked from coming up through the gums by another tooth, bone or soft tissue.
A support used to replace a natural tooth and root or to support a bridge or denture that is surgically anchored into the jawbone.
A filling cast to fit the missing portion of the top edges of a tooth and cemented into place; see also onlay.
A thin plastic or porcelain shell applied to the front of a tooth to restore, strengthen, or improve its appearance.
When the upper and lower teeth don’t line up to bite and chew properly.
Teeth in the back of the mouth with a broad chewing surface for grinding food.
An acrylic appliance worn while sleeping to prevent damage caused by teeth clenching or grinding (also known as bruxism).
Minimal sedation that allows the patient to be awake and able to respond to the dentist during a procedure.
nursing bottle syndrome
Severe decay in baby teeth due to sleeping with a bottle of milk or juice.
A restoration that extends over the cusps of the tooth (but does not cover the entire tooth).
Dentist specialist who diagnoses diseases of the mouth and jaw.
Dentist specialist who removes impacted teeth and repairs fractures of the jaw and other damage to the bone structure around the mouth.
Dentist specialist who corrects misaligned teeth and jaws, usually with braces.
When the upper teeth stick out over the lower teeth.
A type of removable denture that rests directly on your gums and is usually secured by implants placed into your upper and/or lower jaw.
Dentist specialist who treats children from birth through adolescence.
The area surrounding the end of a tooth root.
An infectious disease causing inflammation around the gum and bone of a dental implant.
Dentist specialist who treats diseases of the gums, tissues and bones that support and surround the teeth.
Chronic inflammation and destruction of supporting bone and tissue membranes around the roots of teeth.
Bacteria-containing substance that collects on the surface of teeth.
Portion of a dental bridge that replaces missing teeth (the artificial tooth).
post and core
An anchor placed in the tooth root following a root canal to strengthen the tooth and help hold a crown in place.
The first set of teeth; also known as baby or deciduous teeth.
Professional cleaning to remove plaque, tartar and stains.
Dentist specialist who replaces missing natural teeth with artificial materials, such as a bridge or denture.
Blood vessels and nerve tissue inside a tooth.
Tooth-colored filling material used primarily for front teeth.
These replace missing or damaged tooth structure with artificial materials such as a filling or crown.
Removable device used to stabilize teeth following orthodontic treatment.
The tooth structure that connects the tooth to the jaw.
Removal of the pulp tissue of a tooth due to decay or injury.
Scraping the roots of a tooth to remove bacteria and tartar.
A thin plastic material used to cover the biting surface of a child’s tooth to prevent tooth decay.
Under the tongue.
Below the lower jaw.
An extra tooth or teeth in addition to the regular number of teeth; also known as hyperdontia.
Deposit of minerals coated with bacterial plaque that builds up on teeth; also known as calculus.
Abbreviation for temporomandibular joint, the ball-and-socket joint connecting the lower jaw to the skull.
A lump of white or yellow hardened material on or in the tonsils.
Process of removing a tooth from its socket in the bone.
Tooth pain caused by air or water pressure in extreme environments; also known as barodontalgia.
Thin covering made of porcelain or composite material covering natural teeth, usually to improve appearance.
The set of molars that grow in during the late teens or early twenties; these may be impacted or grow in crooked and require removal.
Dry mouth caused by salivary glands that aren’t working properly.
An image taken of bones, teeth and restorations made with a minimal amount of radiation, also known as a dental radiograph.