Dental Insurance Terms

Use this guide to familiarize yourself with the terms that you may find in your dental plan and make the most of your benefits.

Annual Maximum: The total dollar amount that a plan will pay for dental care for an individual member or family member (under a family plan) for a specified benefit period, typically a calendar year.

Balance Billing:  When a Participating Dentist bills a member for amounts disallowed by Delta Dental that are also not allowed to be charged to the member. Participating Dentists agree to accept the fee approved by Delta Dental as payment in full and cannot bill a member for any difference. 

Benefit Year: The 12-month period a member’s dental plan covers, which is not always a calendar year.

Certificate of Coverage (or Policy/Benefit Booklet): A booklet received from Delta Dental that explains a member’s benefits coverage in detail.

Claim/Claim Form: Information a dentist submits to the dental plan to get paid for services performed for a member. A dentist is responsible for the accuracy of all information on a claim form.

Coinsurance: The percentage of the costs of services paid by the patient. For example, a benefit that is paid at 80% by the plan creates a 20% coinsurance obligation for a member.

Contracted Fee: The fee for each single procedure that a dentist has agreed to accept as payment in full for covered services provided to a member.

Coordination of Benefits (COB): When a member has more than one dental plan, this is the process that the plans use to determine the amount that each will pay.

Copayment: The member’s share of payment for a given service. The copayment is usually expressed as a percentage of a dentist’s contracted fee, but can be expressed as a member’s preset share of payment for a given service.

Covered Service: A dental treatment for which payment is provided under the terms of a member’s dental plan.

Credentialing: A process designed to ensure a dentist is properly trained and licensed to treat members before becoming a part of a Delta Dental network. This includes the review of documentation pertaining to a dentist, including verification of licenses, specialty certification, malpractice insurance, infection control procedures, and OSHA requirements.

Deductible: A dollar amount that each member must pay toward covered services before Delta Dental’s benefits are paid. This is often referred to as the member’s out-of-pocket costs.

Dependents: Anyone other than the primary member that is covered by a dental plan. This could be a child or spouse.

Dual Coverage: When a member has coverage under two different dental plans. Primary and secondary carriers must coordinate the two plans.

Effective Date: The date the coverage under a dental plan begins.

Exclusions: Dental services that are not covered by a dental plan.

Explanation of Benefits (EOB): A paper or electronic document provided by Delta Dental detailing the dental treatments and services that were paid for on a member’s behalf. It is different from a bill.

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

Fee Schedule: A list of charges for specific dental treatments used to reimburse dentists on a fee-for-service basis.

HIPAA: 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, and control administrative costs. See the Administrative Simplification section of the Department of Health and Human Services’ web site for more information at http://aspe.os.dhhs.gove/admnsimp/

In-Network Dentist: A dentist who has agreed to be a part of Delta Dental’s network and accept pre-established fees for his or her professional dental services.

Limitations: Services that are limited or excluded from a dental benefit plan. A member is typically responsible for charges associated with plan limitations. These services are often referred to as optional services.

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

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. Under HIPAA, all providers were required to have an NPI by May 23, 2007.

Member: An individual who has signed up for dental coverage from Delta Dental directly or through a Group.

Network: Consists of participating dentists who have signed up with Delta Dental to provide dental treatment within certain administrative guidelines at agreed-upon fees.

Open Enrollment: The period of the year during which employees or qualified individuals can enroll in or make changes to their benefits plan.

Out-of-Network Dentist: A dentist who has not signed up to participate in a Delta Dental network.

Protected Health Information (PHI): Personal information such as medical history, which is required to be stored securely by a health care entity.

Premium: The amount the member pays for dental benefits, which can be 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. This can help a member budget for dental procedures and decide how to proceed with treatment.

Processing Policies: Internally developed policies used as a tool and guide to determine coverage for members. Processing policies are continually reviewed and updated to reflect current information. If a processing policy is applied to a billed serviced, it will be explained in your Explanation of Benefits (EOB).

Termination Date: The date a member’s dental coverage ends or when a member is no longer eligible for benefits.

Waiting Period: A period of time before a member is eligible to receive benefits for all or certain treatments. It typically applies to expensive services such as dentures or crowns.