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A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Abcess

An infection of a tooth, soft tissue, or bone.

Abutment

Tooth or teeth on either side of a missing tooth that support a fixed or removable bridge.

Accepted fee

The dollar amount that the attending dentist has agreed to accept as payment in full from the insurance company and the patient. 

Acrylic resin

The plastic widely used in dentistry.

Alveolar bone

The bone surrounding the root of the tooth, anchoring it in place; loss of this bone is typically associated with severe periodontal (gum) disease.

Amalgam

A metal alloy used to fill and impede an area of decay (cavity) on the surface of a tooth; also known as "silver fillings." Dental amalgam is a mixture of silver, mercury and other materials.

Anesthesia

A type of medication that results in partial or complete elimination of pain sensation; numbing a tooth is an example of local anesthesia.

Apex

The tip of  the root of a tooth.

Appliance

Any removable dental restoration or orthodontic device.

Baby Bottle Tooth Decay

Tooth decay in infants and children, most often affecting the upper front teeth, caused by sweetened liquids left clinging to the teeth for long periods, often from feeding bottles or pacifiers.

Balance billing

Dentist fees that the enrollee is billed for above the enrollee’s portion of the coinsurance. Some dentists agree to accept an insurance company's contracted fees and not to bill above that amount.

Basic services/basic benefits

A category of dental services in a fee-for service dental benefits contract that usually includes restorations (fillings) and oral surgery (simple extractions).  This may vary by provider.

Bicuspid

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. Adults have eight bicuspids, or premolars, two in front of each group of molars.

Bite-wing

A single X-ray that shows teeth in a select area on the same film.

Calendar Year

The period of time beginning January 1st and ending on December 31st of the same year. The first Calendar Year of coverage is generally when your policy becomes effective and ends on the first December 31st after your Effective Date of coverage.

Calendar Year Maximum Amount

The maximum amount of benefits payable in a Calendar Year.  Also known as Maximum Allowable Benefit.

Capitation

Compensation paid to general dentists in closed panel benefit plans (such as a DHMO) for providing covered services to enrollees assigned to their office.

Certificateholder

The Insured Person under the Policy.

Child

In most cases is defined with one of the following:
  • An Insured Person's natural child;
  • An Insured Person's lawfully adopted child;
  • A child placed for adoption with an Insured Person;
  • An Insured Person's stepchild;
  • An Insured Person's foster child;
  • A child for whom the Insured Person has been appointed legal guardian by a court of competent jurisdiction and who resides with and who is dependent upon the Insured Person in a regular parent-child relationship; or
  • A Child of the Insured Person for whom the Insured Person is obligated to provide medical child support pursuant to a Qualified Medical Support Order, provided that the requirement for qualifications of the order as outlined in the Policy are met.

Cleaning

Closed Panel Plan

A type of dental plan where enrollees must visit a pre-selected or assigned network dentist to receive benefits. A DHMO is an example of a closed panel plan.

Coinsurance

The enrollee’s share, expressed as a fixed percentage, of the benefit allowance. For example, a benefit that is paid at 80 percent by the plan creates a 20 percent coinsurance obligation for the enrollee. Coinsurance generally applies after the enrollee meets a required deductible.

Contracted dentist

A dentist who has a contract with a dental insurance provider to participate in their network. The dentist agrees to accept a specific determination of fees as payment in full for services rendered to an enrollee of the provider's plan. Also known as participating dentist, network dentist or contracting dentist.

Contracted Fee

The fee for a specific procedure that a contracted dentist has agreed to accept as payment in full for services provided.

Coordination of Benefits

A carrier process that determines the order of payment and amount each carrier will pay when a person receives dental services covered by more than one benefit plan.  Coordinating benefits guarantees that carriers will not pay more than 100 percent of the dental charges for services paid when dual coverage is involved.

Copay/Copayment

The fixed dollar amount that is payable by a Covered Person to a provider at the time of service in connection with specific Covered Charges.

Covered Charge

The Reasonable and Customary Charge for a Medically Necessary Covered Procedure which is performed by a Dentist or a Dental Hygienist acting under the supervision and direction of a Dentist.

Covered Person

A person who has satisfied all of the following requirements:
  • he or she is eligible for coverage under the Policy, either as an Insured or as a Dependent;
  • he or she has been accepted for coverage under the Policy or has been automatically added;
  • premium has been paid for him or her; and
  • his or her coverage has become effective and has not terminated.

Crown

A restoration to improve the strength or appearance of a tooth, which can be made from many substances, and which completely caps or surrounds a tooth or dental implant, usually bonded by dental cement.

Cusps

The high points on the chewing surfaces of the back teeth.

DDS

Doctor of Dental Surgery -- equivalent to DMD, Doctor of Dental Medicine.

Debridement

Removal of plaque and calculus which obstructs the dentist's ability to perform an evaluation. 

Decay

Decomposition of tooth structure.

Deciduous teeth

Commonly called "baby teeth" or primary teeth; usually the first set of 20 teeth.

Deductible

A dollar amount that an enrollee or family must pay for certain covered services before an insurance provider begins paying benefits.

Demineralization

Loss of mineral from tooth enamel just below the surface in a carious lesion; usually appears as a white area on the tooth surface.

Dental Arch

The curving structure formed by the teeth in their normal position.

Dental Health Maintenance Organization

A type of dental insurance in which members receive all their dental care from a network of dentists at a fixed price. These plans will not pay for treatments for dental care received outside the network except in special circumstances. Members pay for treatment at the time of service, but there are no waiting periods;and the costs are generally lower compared to other types of plans. See also DHMO.

Dental Hygienist

A person who is licensed to practice dental hygiene in the state where services are rendered and is acting under the supervision and direction of a Dentist and within the scope of that license.

Dentin

Hard tissue which forms the bulk of the tooth and is mineralized in the mature state.

Dentist

A person who is a legally licensed doctor of dental surgery, dental medicine or dental science in the state where services are rendered and is acting within the scope of that license.

Dentures

A prosthetic device constructed to replace missing teeth.

Denture Base

The part of a denture that makes contact with soft tissue and retains the artificial teeth

Dependent

An Insured Person's: 1) Lawful spouse 2) Unmarried Child who is primarliy dependent upon the Insured Person for support and maintenance and is: A) Less than 19 years of age; or B) Between 19 and 26 years of age provided, however, that the Child is dependent upon the Covered Person for support and maintenance and a full-time student actively attending an accredited college, vocational or high school.

DHMO

A type of dental insurance in which members receive all their dental care from a network of dentists at a fixed price. These plans will not pay for treatments for dental care received outside the network except in special circumstances. Members pay for treatment at the time of service, but there are no waiting periods and the costs are generally lower compared to other types of plans. See also Dental Health Maintenance Organization.

Diagnostic and preventive services

A category of dental services in a fee-for-service contract that usually includes oral evaluations, routine cleanings, x-rays and fluoride treatments.  Contracts vary by dental plan provider.

Diastema

A space, such as one between two adjacent teeth in the same dental arch.

Dry mouth

A condition in which the flow of saliva is reduced and there is not enough saliva to keep the mouth moist. Also called xerostomia.

Dry socket

A common complication that occurs when either a blood clot has failed to form in an extracted tooth socket or else the blood clot that did form has been dislodged.

Dual Coverage

When dental treatment for an enrollee is covered by more than one dental plan. A child covered by both parents'  benefit plans is an example of dual coverage. 

Edentulous

Having no teeth.

Effective Date

The date a dental benefits contract begins and the member can begin using the benefits.

Emergency

A dental condition characterized by the sudden onset of acute symptoms of sufficient severity that the absence of immediate dental attention could reasonably result in:
  • permanently placing the Covered Person's health in jeopardy:
  • causing other serious dental or health consequences; or
  • causing serious impairment of dental function.

Endodontics

A field of dentistry concerned with the biology and pathology of the dental pulp and root tissues of the tooth.  A root canal is a commonly performed endodontic procedure.

Endodontist

A dental specialist concerned with the causes, diagnosis, prevention, and treatment of diseases and injuries of the human dental pulp or the nerve of the tooth.

Family Member

A person who is related to a Covered Person in any of the following ways: spouse, brother-in-law, sister-in-law, son-in-law, daughter-in-law, mother-in-law, father-in-law, parent (includes stepparent), brother or sister (includes stepbrother and stepsister), or Child.

Fee-For-Service

Compensation paid to dentists based on a mutually-agreed amount per service. Fee-For-Service plans generally permit enrollees the freedom of using a network or non-contracted dentist to provide the service.  See also indemnity and traditional plan.

Filling

An informal term that applies to both the process of placing material in a cavity in a tooth to prevent decay and the material itself, which can consist of a variety of substances.

Fistula

A gum boil; a channel emanating pus from an infection site.

Flap surgery

The lifting of gum tissue to expose and clean underlying tooth and bone structures.

Flossing

Cleaning between between the contact areas of teeth with a thread-like material ; part of a good daily oral hygiene plan.

Fluoride

A mineral that helps strengthen teeth enamel making teeth less susceptible to decay. Fluoride is ingested through food or water, is available in most toothpastes, or can be applied as a gel or liquid to the surface of teeth by a dentist.

Gingivectomy

A gingivectomy removes and reshapes loose, diseased gum tissue between the teeth and gums to get rid of pockets. A gum specialist (periodontist) or oral surgeon often will do the procedure.

Indemnity  
This type of dental insurance allows you the freedom to visit any dentist you like and the plan pays a set percentage of your charges for covered services. An indemnity dental plan may require that you pay a percentage of your fees up front for services and then submit a claim to the insurance company for reimbursement. See also traditional plan or fee-for-service.

In-Network Provider

A Dentist who is under contract with the insurer or an insurer's subcontracted vendor.

Insured/Insured Person/Member

The individual named on the Schedule of Benefits as the Insured who has: (a) submitted an application for coverage on himself or herself, his or her Dependents, or both; (b) meets the eligibility and effective date provisions set forth in the Certificate evidencing coverage under the Policy; (c) is approved for coverage by insurer; and (d) for whom all applicable premiums are paid, and therefore has coverage under the Policy.

Medically Necessary

A treatment, drug, device, procedure, supply or service that is necessary and appropriate for the diagnosis or treatment of a Covered Person's condition in accordance with generally accepted standards of dental practice in the United States at the time it is provided.

A treatment, drug, device, procedure, supply or service shall not be considered as Medically Necessary if it:

  • is Experimental/Investigational;
  • is provided solely for education purposes or the convenience of the Covered Person, a Family Member, Dentist, Hospital or any other provider;
  • exceeds in scope, duration, or intensity the level of care that is needed to provide safe, adequate and appropriate diagnosis or treatment.
  • is for maintenance or preventive care;
  • could have been omitted without adversely affecting the person's condition or the quality of dental care; or
  • can be safely provided to the patient on a more cost effective basis or pursuant to a more conservative form of treatment.

Note that with most insurance carriers, the fact that a Dentist may prescribe, order, recommend, or approve a service, supply or level of care does not, of itself, make the treatment Medically Necessary or make the charge a Covered Charge under the Policy. Most insurance carriers reserve the right to determine whether a service, supply or drug is Medically Necessary.

Out-of-Network Provider

A Dentist who is not under contract with the insurer or one of its subcontracted vendors.

Plan Year

The 12-month period between when coverage under an insurance policy becomes effective and is due for renewal.

Policy

The contract providing a description of benefits, issued to the Policyholder.

Policyholder

Means the individual or group, in whose name the Policy is issued.

PPO Service Area

The geographical area in which the insurer has arranged to provide PPO services to Covered Persons.

Preferred Provider Organization (PPO)

A designated entity within the PPO Service Area under contract with the insurer or one of its subcontracted vendors to provider certain services at a reduced reimbursement rate within a PPO Service Area. The insurer or one of its subcontracted vendors will contract with In-Network Providers to provide services covered by the Policy.

Prescription Drugs

Drugs which may only be dispensed by written prescription under Federal law, and approved for general use by the Food and Drug Administration.

Prophylaxis

Cleaning and surface scaling of teeth to remove stains, calculus, and plaque deposits.                     

Reasonable and Customary Charge

The most common charge for similar professional services, drugs, procedures, devices, supplies or treatment within a Geographic Area (as determined by the insurer) in which the charge is incurred. The most common charge means the lesser of:

  • the actual amount charged by the provider;
  • the negotiated rate;
  • the usual charge which would have been made by a provider (Dentist, Hospital, etc) for the same or a comparable professional services, drugs, procedures, devices, supplies or treatment within the same Geographic Area, as determined by the insurer.

Root Canal

The removal of the pulp of a tooth to clear away infection, then cleaning, shaping and filling of the tooth's root canals to protect it from further infection.

Routine Exam

Generic visit/consultation with a dentist.

Traditional Plan

This type of dental insurance allows you the freedom to visit any dentist you like and the plan pays a set percentage of your charges for covered services. An indemnity dental plan may require that you pay a percentage of your fees up front for services and then submit a claim to the insurance company for reimbursement. See also indemnity and fee-for-service plan.

X-Ray

Pictures of teeth, bones, and the tissue around them, which are used by dentists to diagnose cavities and condition of a tooth.

Waiting Period
A waiting period is the length of time an insurance company requires you wait after your  coverage begins before they will pay for certain procedures. 


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