Delta Dental Common Terms and Definitions
A patient's ability to obtain care is determined by factors such as the availability of services, their acceptability to the patient, the location of facilities, transportation, hours of operation and cost of care.
The fees, on which program deductibles, maximums and coinsurance percentage are 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 (MPA) or maximum allowable charge (MAC). 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.
The benefit allowed for the least costly, most commonly accepted service or supply that could be used to treat a dental problem for which there are other, more costly treatment options that the covered person selects. (Not all benefit plans offer alternate benefits.)
Assigned identification number created to replace use of Social Security numbers for identification of enrollees.
The total fee that must be paid by the member company and the patient. Participating dentists have agreed to accept a maximum plan allowance (MPA) based on agreements signed with Delta Dental. Non-participating dentists use the submitted amount.
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. Non-participating dentists are not limited in the amount they may balance-bill.
Basic procedures/basic benefits
In a standard dental benefit contract, basic procedures include restorations (fillings, etc.), oral surgery (extractions), endodontic (root canals) and periodontal treatment (root planning).
Benefit waiting period
A period of time that a person must be enrolled on the dental plan before becoming eligible for a particular class of procedures.
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.
Current Dental Terminology (CDT)
Under the Health Insurance Portability and Accountability Actof 1996 (HIPAA), the American Dental Association's CDT codes are the required standard for electronic dental claims.
Consolidated Omnibus Budget Reconciliation Act (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 (up to 29 months if the individual is disabled, and up to 36 months in the case of divorce).
The percentage of the costs of services paid by the patient after the deductible, if any, is met. This is a characteristic of indemnity insurance, POS and PPO plans. The amount of coinsurance varies with the type of covered services. See copayment.
- For root canal therapy: On the date the canals are permanently filled.
- For fixed bridges (fixed partial dentures), crowns, inlays, onlays and other laboratory prepared restorations: On the date the restoration is cemented in place.
- For dentures and partial dentures (removable partial dentures): On the date that the final appliance is first inserted in the mouth.
- For all other services, on the date the procedure is started.
- For benefit payment purposes, the date completed will be considered as the date when a covered service is incurred.
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.
The enrollee's share of payment for a given service. The copayment is usually expressed as the enrollee's pre-set share of payment for a given service. See coinsurance.
For PPO dentists, the lesser of the PPO dentist's allowable fee or the fee actually charged. For Premier® participating dentists, the lesser of the Premier maximum plan allowance (MPA) or the fee actually charged. For all other dentists, the lesser of the non-participating maximum plan allowance (MPA) or the fee actually charged.
Services for which payment is provided under the terms of the dental benefit contract.
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.
Date of service
The actual date the service was rendered. With multi-stage procedures, except orthodontics, the date of service is the final completion date. Example: the insertion date of partial denture or the cementation of a permanent crown. See completed.
DDS stands for doctor of dental surgery. DMD stands for doctor of dental medicine.
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.
Delta Dental PPOSM
Delta Dental PPO is one of our three contracted national network–based programs. Participating dentists agree to fee schedules as payment in full. These PPO schedules provide deeper discounts that result in savings to the group and enrollees. As with all of the Delta Dental networks, dentists agree to processing policies and are prohibited from billing and collecting fees in excess of the agreed-upon schedule. This product allows enrollees to visit any dentist but offers deeper savings when visiting a PPO network dentist.
Delta Dental PPOSM plus Premier
Delta Dental PPO plus Premier affords all of the benefits of Delta Dental PPO. Plus, enrollees who access a participating Delta Dental Premier dentist (who is not in the PPO network) receive the benefit of that provider's contracted fee. This product provides enrollees with our unique safety-net feature, giving a level of financial security for enrollees and groups that are unequaled in the industry.
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.
Any person duly licensed as a doctor of dental medicine (DMD) or doctor of dental surgery (DDS) practicing within the authority of his/her license. The term dentist includes dental specialists.
- Participating dentist — A dentist who has a contractual agreement with Delta Dental to furnish covered services to subscribers and dependents. A participating dentist can be either a Delta Dental Premier or Delta Dental PPO dentist.
- Non-participating dentist — A dentist who has no contract with Delta Dental. Claims are processed based on the non-participating maximum plan allowance (MPA) and the non-participating dentist can bill the subscriber their full fee.
Diagnostic and preventive procedures (D&P)
In the standard client contract, these procedures include oral examinations, cleanings, X-rays, fluoride treatment and space maintainers.
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.
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.
Eligibility waiting period
A period of time a new employee must wait until he/she is eligible for the dental benefits plan.
Dental services that are immediately required to relieve pain, swelling or bleeding, or required to avoid jeopardizing the patient's health.
The portion of the insurance premium paid by the employee.
A dental specialist who treats the root and nerve of the tooth.
Electronic funds transfer (EFT)
Provides for electronic payments to dentists and vendors.
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.
Exclusive provider organization (EPO)
A dental benefit plan design in which enrollees must have treatment provided by a PPO dentist in order to receive any benefits. If an out-of-network dentist provides treatment, the EPO will offer no coverage for the visit.
Explanation of benefits (EOB)
An industry term for the notice that enrollees receive after a claim is processed. The EOB provides information about fees charged, procedures provided and the enrollee's payment portion. See notice of payment (NOP).
General dentists provide a full range of dental services for the entire family.
Health 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' website for more information at http://aspe.dhhs.gov/admnsimp/index.shtml.
Health care services
It means any services included in the furnishing to any individual of medical, mental, dental or optometric care or hospitalization or nursing-home care or incident to the furnishing of such care or hospitalization, as well as the furnishing to any person of any and all other services for the purpose of preventing, alleviating, curing or healing human physical or mental illness or injury.
Health coverage plan
Delta Dental of Colorado is a health coverage plan as defined by the Colorado Division of Insurance. It means a policy, contract, certificate or agreement entered into by, offered to or issued by a carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services.
Someone who enrolled after the period of initial eligibility (either an employee or a dependent). Late enrollees must wait a certain time before benefits for a particular type of service can be paid. (Delta Dental of Colorado's standard is a 12-month waiting period for all services other than diagnostic or preventive.) Members who enroll within 31 days after a qualifying event are not considered late enrollees; neither are children who enroll prior to their fourth birthday.
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.
Maximum allowable charge (MAC) plan
A feature of Delta Dental PPO, a MAC plan limits the amount Delta Dental will pay for a procedure to the PPO discounted fee schedule for all dentists. A Premier dentist can balance-bill the patient the difference between the PPO fee and the Premier MPA.
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).
Maximum plan allowance (MPA)
The highest amount allowed for payment to Premier dentists. Premier participating dentists are reimbursed at the level of the billed amount, or the maximum plan allowance, whichever is less.
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.
A federal health care insurance program for people aged 65 and over and 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.
National provider identifier (NPI)
HIPAA-mandated standard provider identifier in electronic claims processing. All providers are required to have an NPI.
Both words refer to the dentists who have agreed to provide treatment within certain administrative guidelines for certain programs (participating dentists). The Delta Dental PPO, Delta Dental Premier and DeltaCare programs all have distinct dentist networks.
Non-duplication of benefits (carve-out)
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.
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.
Non-participating maximum plan allowance (MPA)
The highest amount allowed for payment to non-participating dentists. The MPA is different between Premier dentists and non-participating dentists.
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. Commonly known in the industry and the Delta Dental system as Explanation of Benefits (EOB) or Notification of Benefits (NOB).
A period of time each year during which employees may enroll or change coverage options. Coverage is effective on the group's anniversary date.
A dental specialist who removes impacted teeth and repairs fractures of the jaw and other damage to the bone structure around the mouth.
A dental specialist who straightens or moves misaligned teeth and/or jaws, usually with braces.
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, as well as 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.
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.
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 contracted fees.
Passive PPO/silent PPO
A preferred provider organization plan that has no differential (i.e., no change in benefit level between in-network and out-of-network benefits). For example, basic benefits are covered at 80 percent whether visiting an in-network or out-of-network dentist. A silent PPO usually refers to the fact that enrollees are not aware that there is a network, and all benefits are paid the same, regardless of the dentist chosen.
A dental specialist who generally limits treatment to children and teenagers.
A dental specialist who treats gums, tissue and bone that support the teeth.
PPO dentist's allowable fee
This is the fee from the PPO discounted fee schedule that the PPO dentist has agreed to accept for treatment under a PPO plan.
A review of a dentist's statement describing his/her planned treatment and expected charges. A patient may ask his/her dentist to submit a pre-treatment estimate, usually when the charges are expected to be more than $400. Delta Dental will notify both the dentist and the patient of Delta Dental's estimated payment, as well as the patient's estimated out-of-pocket responsibility.
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. Delta Dental's PPO is called Delta Dental PPO.
Preventive describes services such as cleanings and fluoride treatments to prevent decay.
Carriers' review of dentists' utilization records.
A dental specialist who replaces missing teeth with artificial materials, such as a bridge or denture.
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.
- For full dentures or partial dentures (removable partial dentures): The date the final impression is taken.
- For fixed bridges (fixed partial dentures), crowns, inlays, onlays and other laboratory-prepared restorations: The date the teeth are first prepared (i.e., drilled down) to receive the restoration.
- For root canal therapy: The date the pulp chamber is first opened.
- For periodontal surgery: The date the surgery is actually performed.
- For all other services: The date service is performed.
These words apply to people who are covered under a Delta Dental plan. Subscribers are the people 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.
Table of allowance/schedule of allowance
A list of the maximum fees for each procedure that a particular program will pay.
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).
Tied to medical
The medical and Delta Dental plans that are offered as a package. Employees enrolled in the medical plan are automatically enrolled in the dental plan with the same type of coverage (employee only, family, etc.).
To break down a procedure into several component parts. This practice is sometimes abused by dentists to get a program to pay more than its contractual benefits by charging a separate fee for each component. For example, if the services for a crown were unbundled, the dentist would submit separate fees for a temporary crown, tissue preparation, precious metal charge and occlusal correction. However, participating dentists are allowed to charge one fee for a crown, which includes all of the above services. Unbundling is also used to describe the trend of customers buying their dental benefits from a separate specialty carrier, as opposed to purchasing all health care coverage from one medical carrier.
Refers to a dental plan in which subscribers may choose to sign up for coverage and typically pay more than 50 percent of the cost of the plan.
Work in progress
The term "work in progress" (also referred to as extended coverage) 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.