• Glossary
  • Glossary

Glossary

Every business has terms and expressions that can be confusing. We’re no exception. So to make sure we’re on the same page with what these terms and expressions mean, we’ve provided short explanations. Our aim is eliminate any and all confusion. If you still have a question or concern, contact one of our product consultants at 513-554-3184 or 888-253-3279 (toll free).

Annual Maximum

The maximum dollar amount a dental plan will pay toward the cost of dental care within a specific period of time, typically from January through December. The member is responsible for paying costs exceeding the annual maximum.

Balance Billing

Billing a patient for the difference between the dentist's actual charge and the amount reimbursed under the patient's dental benefit plan.

Copayment

The amount which a member is required to pay for certain dental services covered under a dental plan. Copayments may be a fixed dollar amount or a percentage of the expense. Members are responsible for payment of the copay directly to the dentist.

Deductible

The amount which a member is required to pay for covered dental services before a dental plan begins to pay.

Dependent

Generally includes spouse, domestic partner and children of the covered member.

Effective Date

The date the member’s dental benefits contract begins/goes into effect. The member is not covered until the contract’s effective date. Sometimes referred to as eligibility date.

Exclusions

Dental services that are not covered by a dental benefits plan.

Limitations

A limit on the amount of benefits paid for a particular covered expense or a limit on the time or frequency of the number of procedures permitted during a specific period. Additional examples of limitations are: age limits, waiting periods or conditions under which certain services are covered.

Member

An individual enrolled in a dental benefits plan.

Predetermination

A process where a dentist submits a dental treatment plan to the dental benefits plan administrator before treatment begins. The plan administrator reviews the treatment plan and notifies the dentist and patient of one or more of the following: patient's eligibility, covered services, amounts payable, copayment and deductibles and plan maximums. Can also be referred to as a pretreatment estimate, preauthorization or precertification.

Premium

The fee (usually monthly) that is paid to the dental benefit plan administrator to provide coverage for a specified period of time.

Preventive, Basic and Major Services

The three levels of coverage often used by dental benefit plans to categorize covered dental services. Each category may have a different co-payment or deductible applied. Can also be referred to as Class I, Class II and Class III.

Service Area

The geographic area in which the plan's benefits are made available.

Subscriber

The person purchasing the benefits plan.

Waiting Period

The period of time a member must be enrolled in a plan before being eligible for benefits.

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