Delta Dental member resources glossary of dental terms

D

deductible

Like car insurance, this is the amount you must pay before your benefit plan begins to pay for your dental treatment. If you have a spouse and dependents enrolled in your plan, you may be subject to a family deductible instead of an individual deductible.

DeltaCare USA dentist

A dentist who is member of the DeltaCare USA network.

Delta Dental dentist

A dentist who is a member of the Delta Dental PPO and Delta Dental Premier networks.

dental provider organization (DPO)

A Delta Dental Insurance Company fee-for-service plan offered only in Texas. This plan uses the Delta Dental PPO™ dentist network.

dentist

A duly licensed dentist legally entitled to practice dentistry at the time and in the state or jurisdiction in which services are performed.

diagnostic and preventive services

A category of dental services that include benefits for oral evaluations, routine cleanings, x-rays and fluoride treatments. These are usually covered at the highest benefit level to encourage you to seek regular care and prevent problems from developing.

dual choice/dual option

When you are offered a choice between two or more dental plans from your employer.

dual coverage

When you are covered by more than one dental benefits plan. Example: When you are covered by your spouse’s plan as well as your own.

E

effective date

The date a dental benefits contract becomes active (effective). Also, the date a member becomes eligible for benefits.

eligibility

Requirements that define who and when a person may qualify to enroll in a plan.

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

When you are enrolled in a plan and can use the benefits as of the effective date.

emergency services

Dental services that are immediately required to relieve pain, swelling or bleeding, or are required to avoid jeopardizing the patient’s health.

endodontics

Dental services that involve treatment of diseases or injuries that affect the root tip or nerve of the tooth.

exclusive provider organization (EPO) plan

A type of plan that requires members to visit network dentists to receive coverage.

expiration date

The date an individual is no longer eligible for his or her 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.

F

fee-for-service

A plan where the dentist is paid a specified amount per service and the member is responsible for any applicable deductible, coinsurance and amounts over the annual maximum.

flex plan

When an employer offers multiple benefit plans to choose from, i.e., a “menu” of plans; also known as a cafeteria plan.

flexible dual choice

An option that allows a member to switch between two dental plans selected by the employer, as often as monthly, removing the restriction of changing plans only during open enrollment. 

freedom of choice

A plan feature that allows members to visit any licensed dentist (usually a fee-for-service plan).

full-time student

A student who is regularly attending an accredited school with an academic schedule of at least 12 credits.

G

grievance

A written or verbal statement of dissatisfaction by a member. Delta Dental follows regulatory requirements in responding to grievances.

H

health care exchange

A government-regulated marketplace of insurance plans offered to individuals or small businesses who lack health care.

HIPAA (Health Insurance Portability and Accountability Act)

A federal initiative with a focus on patient privacy and allowing people to keep their health insurance even when changing jobs. 

health maintenance organization (HMO)

A health care option where members receive most or all of their treatment from a primary care medical or dental office to which they are assigned. The primary care dentist may refer a member to a specialist when needed. A dental HMO may be be abbreviated as DHMO.

I

in-network/out-of-network

Services provided in a plan either by a contracted or non-contracted dentist.

• In-network dentists have agreed to participate in a plan and to provide treatment according to certain requirements and to accept contracted fees as full payment.
• Out-of-network dentists are not held to these requirements.
  
  

Depending on the plan, benefit levels could differ depending on whether the member visits an in-network or out-of-network dentist.

individual

The eligible member (primary member).

L

least expensive alternative treatment

When there are multiple treatment options for a specific condition and the dental plan pays for the least expensive treatment.

lifetime maximum

The total dollar amount a plan will pay for a specific dental service for the life of the member or the plan. 

limitations and exclusions

Limitations are usually related to a specific time or frequency — for example, a plan may cover only two cleanings in a 12-month period or one cleaning every six months. Exclusions are services not covered by a plan.

M

major services

A category of services that include procedures such as crowns, dentures and implants. 

maximum contract allowance

The amount on which Delta Dental bases its payment (for example, a benefit level of 80% would be 80% of the contract allowance). Depending on the contract with the purchaser, the allowance may be the same as the accepted fee, a PPO fee, a table of allowance fee or some other amount.

Medicaid and Medicare

Medicare and Medicaid are two government-sponsored programs designed to help cover health care costs.

• Medicare is a federal program that provides health coverage for people 65 and older or who have a severe disability, no matter their income.
• Medicaid is a state and federal program that provides health coverage for people with a very low income.
  
  

People can be eligible for both Medicare and Medicaid.

member

A person enrolled in a dental plan; also known as subscriber, beneficiary or insured.

N

network

A group of contracted dentists who agree to certain fees and other contractual requirements.

Non-Delta Dental dentist/non-participating dentist

A dentist who does not contract with Delta Dental and who is not contractually bound to abide by Delta Dental’s administrative guidelines.

O

open access

A plan that allows members to visit the dentist of their choice, including specialists, without having to get a referral from a primary care dentist or the dental carrier.

open enrollment

The time when people can enroll in, change or cancel dental coverage.

open network plan

A plan where members can visit any licensed dentist and can change dentists at any time without contacting Delta Dental.

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.

out-of-pocket costs

Any amount the member is responsible for paying, such as any deductible, copayment or coinsurance, amount over the annual or lifetime maximum and for non-covered services.

P

participating dentist

Any dentist who contracts with Delta Dental.

patient's share

The portion of a dentist’s fee that a member pays for covered services. See “out-of-pocket costs.”

preferred provider organization (PPO)

An open network, fee-for-service plan that allows members to visit any licensed dentist but usually has lower costs and may have increased benefits when visiting a network dentist.

premium

The amount a member pays for coverage. This amount can be taken out of a paycheck on a recurring basis or paid in full in advance of the benefit year.

prepaid plan

A dental HMO plan featuring set copayments, no annual deductibles and no maximum limits for covered services.

pre-treatment estimate

Requested by a dentist on behalf of a patient, this provides the member with an estimate of coverage and out-of-pocket costs for a proposed treatment plan.

primary member

The person who has the coverage through his or her employer or who is responsible for plan payments; also known as member. A spouse or dependent children may be covered under the primary member’s plan.

procedure code

The number given to a dental procedure as defined by the American Dental Association. These codes are standardized and used throughout the dental industry.

provider

Any licensed dentist (including general dentists and specialists) who performs dental services for a member. This person can also be a dental hygienist, X-ray technician or other practitioner who provides dental services.

R

radiograph

Technical term for an X-ray.

S

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.

submitted fee

The amount billed by a dentist for a specific procedure.

summary plan description

A document that explains benefits and provisions of the dental plan; also known as a benefit booklet.

T

table of allowances

A plan that provides a list of covered services and the maximum amount a plan will pay for each procedure. Members pay the difference between the amount the dentist charges and what the plan pays. 

U

unbundling of procedures

To break down a procedure into several component parts. By charging a separate fee for each component, the overall fee for the procedure might be higher, resulting in increased cost to the member. Contracted dentists agree they will not unbundle procedures when billing. 

V

voluntary plan

A plan where members can sign up for coverage and pay most or all the cost. It’s also known as an employee-funded plan.  

W

waiting period

The amount of time a person must be enrolled in a plan before being eligible for certain benefits.

workers' compensation

Benefits paid to an employee who experiences a work-related injury or illness.