Some words you need to know

Annual maximum: The most a dental plan will pay toward your dental care within a specific 12-month period, usually a calendar year. Also called “maximum benefit.”

 

Balance billing: The practice of billing a patient for the difference between what the dentist charges and the agreed-upon charge established by Delta Dental. In-network dentists cannot balance-bill patients.

 

Benefit year: The 12-month period your dental plan covers, which is not always a calendar year.  For example, a benefit year could run June-May instead of January–December.  This is also known as a plan year. 

 

Certificate of Coverage: A booklet you receive from Delta Dental that explains your benefits coverage in detail.

 

Claim/Claims form: Information the dentist submits to the dental plan to get paid for services performed for a patient.

 

Coinsurance: A fixed percentage of a dental treatment cost that you share with your dental plan. For example, Delta Dental may pay for 80 percent of a given service, while you are responsible for 20 percent. Coinsurance kicks in after you meet your annual deductible.

 

Contracted fee: The amount set by Delta Dental that an in-network dentist has agreed to charge for a service.

 

Coordination of benefits: Guidelines that determine how each dental plan pays when you are covered by more than one dental plan.

 

Copayment: A set dollar amount you are required to pay your dentist for a service. An enrollee usually has a copayment or coinsurance, but not both. Also known as “copay.”

 

Covered service: A dental treatment or procedure paid for – either partially or fully – by your dental plan.

 

Credentialing: A process to ensure a dentist is properly trained and licensed to treat patients in their state before being able to be a part of Delta Dental’s networks.

 

Deductible: A set dollar amount you are responsible for before your dental plan begins to pay for covered services.

 

Dependents: Anyone covered under a dental plan other than the primary subscriber. For example, a spouse or children.

 

Dual coverage: Coverage under two separate dental plans — for instance, if a child is covered by dental plans from both parents. Also see “Coordination of Benefits.”

 

Effective date: The date you can start using your dental plan.

 

Exclusions: Dental services or procedures not covered by your dental plan.

 

Explanation of Benefits (EOB): A document Delta Dental provides after a procedure. It contains a summary of the treatments you received, including the treatment cost, the portion covered by your dental plan and the portion you may owe. An EOB is not a bill.

 

General dentist: A primary dental care provider with a broad range of general oral health expertise. General dentists perform preventive care as well as many restorative procedures such as fillings, crowns, implants and more.

 

Group: A company or organization that provides dental plans to its employees or members. The group works with Delta Dental to select the plan type, benefit levels, maximums and member eligibility.

 

Fee schedule: A list of charges for specific dental treatments agreed to by both the dental plan and the dentist.

 

HIPAA:  Stands for the “Health Insurance Portability and Accountability Act of 1996,” a federal law intended to improve access to health coverage, limit fraud and abuse, protect personal health information (PHI), and control administrative costs.

 

In-network dentist: A dentist who has agreed to be part of a Delta Dental network. In-network dentists agree to accept pre-established fees for services. Also called “participating dentist.”

 

Limitations: Conditions, such as age and period of time covered, that restrict a dental plan’s coverage for certain services.

 

Lifetime maximum: The maximum amount a plan will pay over the course of a lifetime. The lifetime maximum may apply to an individual or a family and usually applies to specific treatments such as orthodontia.

 

Maximum Plan Allowance (MPA): The amount set by Delta Dental that a Delta Dental Premier® dentist has agreed to charge for a service. For Premier dentists, Delta Dental will pay at the MPA or the actual billed amount, whichever is less.

 

National Provider Identifier (NPI): A unique identification number used to identify a health care professional as an alternative to their dental license number.

 

Member: A person who has signed up for dental coverage from Delta Dental. If family coverage is offered, additional people covered will be listed as the member’s spouse or dependents.

 

Network: Dentists who have signed up with Delta Dental to provide dental care at agreed-upon fees.

 

Optional services: Procedures not covered under the terms of a dental benefits contract. Delta Dental will review claims for optional services to determine what, if any, amount will be paid for the service.

 

Open enrollment: The period of time in which employees or qualified individuals can enroll in or make changes to benefit plans.

 

Out-of-network dentist: A dentist who has not signed up to participate in a Delta Dental network. Also called “Non-participating dentist.”

 

Protected Health Information (PHI): Personal information about a patient, such as a Social Security number and medical history, which is required to be stored securely by health care entities such as a doctor, dentist, health clinic or health insurer.

 

Premium: The amount the enrollee pays for dental benefits, usually paid monthly, quarterly or annually.

 

Pre-treatment estimate: A treatment plan usually submitted by a dentist for Delta Dental to review and provide an estimate of benefits before treatment starts. Pre-treatment estimates can help you budget for dental procedures. They can also help you and your dentist decide how to proceed with a treatment. This is sometimes referred to as Pre-Authorization. Also called “pre-determination.”

 

Processing policies: Internally developed policies that are used as a guide and tool by our claims processing teams and clinical consultants to determine coverage for our members. Processing policies are continually reviewed and updated to reflect current information and may change occasionally. If a processing policy is applied to a billed service, it will be explained on the Explanation of Benefits (EOB).

 

Termination date: The date your dental coverage ends or you are no longer eligible for benefits.

 

Waiting period: A period of time before you are eligible to receive benefits for all or certain dental treatments. This typically applies to more expensive services such as crowns or dentures.