allowed amount
For covered services, the allowed amount under the AARP Dental Insurance Plan, administered by Delta Dental Insurance Company is the lesser of the dentist’s submitted fee or the PPO maximum allowance if the dentist is a Delta Dental PPO™ Dentist or a Non-Delta Dental Dentist. For Delta Dental Premier® contracting dentists, the allowed amount is the lesser of the dentist’s submitted fee, the PPO maximum allowance or the Delta Dental Premier maximum allowance. For non-covered services, the allowed amount is zero.
annual deductible
The cumulative total amount members must pay toward treatment before their health care benefits are paid in a calendar year. Also called a deductible.
annual maximum
The most the AARP Dental Insurance Plan, administered by Delta Dental Insurance Company will pay toward dental care within a calendar year. Also called the maximum benefit.
authorization
The process by which Delta Dental determines whether a procedure or treatment is a referable benefit under the member’s plan.
benefit waiting period
The 12-month period of continuous enrollment that a member must complete before certain dental procedures become covered benefits.
benefits
Dental services provided under the terms of the contract as specified in the description of benefits and copayments.
calendar year
The period beginning on Jan.1 and ending on Dec. 31.
claim form
A written or electronically submitted document to request payment for completed dental treatment or to request a pre-treatment estimate for proposed dental treatment. The claim form is also sometimes called an attending dentist’s statement.
contract
The agreement between Delta Dental and contractholder, including the application for the contract, the attached schedules, and any appendices, endorsements or riders. The contract constitutes the entire agreement between the parties.
contracted dentist
A dentist who has a contract with Delta Dental, also known as a participating or network dentist. Contracted dentists agree to provide covered services at pre-negotiated fees, which generally means lower out-of-pocket costs for members compared to visiting an out-of-network dentist.
contract holder
AARP Dental Insurance Trust.
copayment
The amount charged to a member by a contract dentist for the benefits provided under this program.
covered services
See benefits.
DeltaCare USA dentist
A dentist who is a member of the DeltaCare USA network. If you have a DeltaCare USA plan, you must select a contract dentist from this network at enrollment and receive treatment from that dentist to access coverage. You can change your selected contract dentist at any time, as long as the new dentist participates in the DeltaCare USA network. Use the Find a Dentist tool and select the DeltaCare USA network to locate participating dentists near you.
Delta Dental dentist
A dentist who is a member of the Delta Dental PPO or Delta Dental Premier networks. Visiting a Delta Dental PPO dentist typically results in the lowest out-of-pocket costs, since PPO dentists agree to the most reduced fee schedule for covered services. Delta Dental Premier dentists are also contracted, but at a different fee schedule, so your costs may be slightly higher than at a PPO dentist. When you visit an in-network dentist, you may pay less than you would when visiting an out-of-network dentist, where the dentist may charge above the plan's allowed amount and bill you for the difference. Use the Find a Dentist tool and select the Delta Dental PPO or Delta Dental Premier network to locate participating dentists near you.
dentist
A duly licensed dentist legally entitled to practice dentistry at the time and in the state or jurisdiction where services are performed. For plan purposes, this includes general dentists and dental specialists. Use the Find a Dentist tool to search for dentists who participate in your plan's network.
domestic partner
A member’s live-in, adult partner. Domestic partners can be the opposite sex or same sex as the member. Some state laws affect allowable coverage. Other terms used are legally domiciled adults and legally domiciled members.
effective date
The date a dental benefits contract becomes active (effective). Also, the date a member becomes eligible for benefits.
eligible dependent
Any of the dependents of a member who are eligible to enroll for benefits and who meet the conditions of eligibility as described under eligibility for benefits.
eligible member
Any AARP member who has been assigned an AARP membership number and who meets the conditions of eligibility as described under eligibility for benefits.
Explanation of Benefits (EOB)
The notice that members and dentists receive after services have been provided and a claim processed. The EOB provides information about the fees charged, what procedures were provided, any adjustments made by the carrier and the member’s coinsurance payment.
full-time student
A student who is regularly attending an accredited school with an academic schedule of at least 12 credits.
individual
The eligible member (primary member).
maximum contract allowance
The amount on which Delta Dental bases its payment. Depending on the specific group contract provision, the allowance may be the same as the accepted fee, a PPO fee, a table of allowance fee or some other amount.
member
An eligible member (primary member) or an eligible dependent (dependent member) enrolled to receive benefits.
network
A collective expression for all Delta Dental dentists who have contracted with Delta Dental to offer services to members and who have agreed to abide by certain administrative guidelines. There are two Delta Dental networks: Delta Dental PPO and Delta Dental Premier. Under the AARP Dental Insurance Plan, administered by Delta Dental Insurance Company, visiting a PPO network dentist generally results in the lowest out-of-pocket costs.
Non-Delta Dental dentist
A dentist who does not contract with Delta Dental and who is not contractually bound to abide by Delta Dental’s administrative guidelines.
out-of-network
An out-of-network dentist is a dentist who does not have a network contract with Delta Dental. For a given plan, an out-of-network dentist refers to a dentist who is not bound by a Delta Dental contract to follow specific fee requirements when treating patients covered under applicable plans.
reasonable
A member exercises prudent judgment in determining that a dental emergency exists and makes at least one attempt to contact their contract dentist to obtain emergency services and, if the dentist is not available, makes at least one attempt to contact Delta Dental for assistance before seeking care from another dentist.
special health care need
A physical or mental impairment, limitation, or condition that substantially interferes with a member’s ability to obtain benefits. Examples include the inability to obtain access to the assigned contract dentist’s facility because of a physical disability and the inability to comply with the contract dentist’s instructions during examination or treatment because of physical disability or mental incapacity.
specialist services
Services performed by a dental specialist, such as oral surgery, endodontics, periodontics, or pediatric dentistry. For certain plans, specialist services must be preauthorized in writing by Delta Dental.
spouse
A partner of the primary member by marriage, civil partnership or domestic partnership. To receive treatment, the person may have defined as a spouse by the laws of the state where the contract is issued and delivered or where the primary member resides.
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Delta Dental or the administrator, as appropriate.
