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Dental Insurance Domain

New to dental insurance, eligibility, and benefits? These definitions will help you understand the data in insurance verification results.

Benefit Period​

The length of time during which the benefit is paid. Dental coverage has both a plan “effective date” and an “end date.” In most cases, the benefit period for the plan will be one year. A Benefit Period can be less than 1 year if a plan is joined after the start of the benefit period for a corporate plan. Benefit periods are typically no longer than one year. Medicaid plans usually have a month-to-month benefit period, and members are continually evaluated for qualification.

Therefore, if the effective date of the plan is January 1, 2020, and the end date is December 31, 2020, unless the plan is renewed before the end date, it will no longer provide coverage as of January 1, 2021.

Claims Address​

The address appearing on an enrollee's or insured's current identification card issued by the health insurance issuer is the current address at which claims are received.

Claims​

The formal payment request submitted by the dental service provider to the dental insurer. A dental claim explains the services and procedures provided by the dentist and team during the visit. This is used to determine how much the insurance company will pay for any procedure or treatment.

Coinsurance​

The amount (usually a percentage) that the patient is responsible for paying for a specific dental treatment, after the insurance company has paid its portion.

For example, if the plan specifies a 20% coinsurance for fillings or crowns, then the insurance will pay 80% of the cost billed by the dentist, and the patient will be responsible for the remaining 20% of the cost for those services.

Plans with Coinsurance typically do not have a Copayment.

Coordination of Benefits​

A set of rules that insurance companies provide if they are the secondary payer, dictating how much of the total allowed amount the insurance will pay AFTER the primary insurance pays its portion. There are four types: Standard, Maintenance, Non-Duplication, and Do Not Coordinate Benefits.

Copayment​

A flat fee per visit/treatment, and does not generally count towards the deductible. Plans with Copayments for procedures typically do not have Coinsurance.

Dependent​

Anyone eligible to be added to a health insurance plan.

A dependent may be a spouse, domestic partner, or child (some plans refer to “spouse and dependents,” meaning that they differentiate between the spouse and the children, usually up to the age of 26).

The subscriber can cover their biological, adopted, and stepchildren. In some cases, the subscriber may also be able to cover a grandchild, an adult child with a disability, a foster child, or someone for whom they are the legal guardian.

Deductible​

The amount that the patient must pay out of pocket before the insurance policy pays for any treatments. Most dental plans do have annual deductibles. Some plans are designed for each individual covered under the plan, while others have a single deductible that applies to all family members included in the plan.

Some plans do not require a deductible (i.e., the Deductible does not apply) for specific basic preventive treatments and services, such as annual check-ups, cleanings, and X-rays.

Downgrades​

Also known as an “alternate benefit” in dental insurance, occurs when dental insurance plans opt to cover the least expensive procedure among what THEY deem to be multiple acceptable options.

In such cases, patients may still receive the treatment option they choose, but if they choose a more expensive option (typically not covered), they'll incur a higher out-of-pocket expense.

Exclusions​

Treatments or procedures that the insurance plan does not cover. Essentially, the cost for the treatment/procedure will be out of pocket (the patient has to pay the full amount).

Fee Schedule​

A list of prices for specific treatments and services that insurers pay dentists, other providers, and suppliers. Insurers calculate schedule fees at their in-network rates. These set the maximum allowable fee a dental practice can bill a patient for covered services and the maximum payable by their plan.

Group​

A company or organization that provides dental plans to its employees.

  • Name: Name of the group (usually an employer) or insurance plan that insures the patient.
  • Number: A number the insurance company uses to distinguish the group under which the patient is insured.

Insurance Plan​

Dental insurance provides coverage for services and treatments related to oral health care. For instance, it can help individuals and families manage the costs of routine dental cleanings and exams, as well as surgeries and emergency procedures. Dental insurance covers a portion of the expenses, so the patient is not left paying all the costs on their own.

Limitations​

Restrictions on when the insurance will pay for a procedure. There are a few types of limitations.

Frequency Limitations​

How often the insurance will pay for a particular procedure to be performed. For instance, you may be permitted to have two dental cleanings per year, or one every six months. Having three cleanings per year or going every four months would mean that one of those cleanings isn’t covered at all, and the patient will have to pay out of pocket for the third one.

Age Limitations​

The ages the insurance covers for a procedure. It’s relatively common for dental insurance to cover treatments like dental sealants or fluoride, but only for children up to a certain age; this age limit may be 12, 15, or even 18 years. Once a child passes that age, the service is no longer covered.

Other Limitations​

There can be many other types of limitations, in addition to frequency and age. These include the procedures that can be performed on the same day, the order in which procedures are performed, and the procedures that may not be covered due to reasons other than those generally not covered by the plan.

Maximum​

There are three types of maximums: annual, unlimited, and lifetime.

  • The annual maximum is the maximum amount the plan will pay toward the cost of all dental care within a given benefit period, typically the calendar year. Many plans do not count standard preventive and diagnostic treatments toward the annual maximum.
  • Unlimited plans have no annual maximum. These plans typically have a higher copay per treatment, but no annual cap on the amount used.
  • The lifetime maximum is the maximum dollar amount the plan will ever pay toward the cost of specific dental services. The most common dental services with lifetime maximums are orthodontic treatment and temporomandibular joint (TMJ) disorders.

Since not all plans are created equal, some will have an annual or lifetime maximum, while others will not.

Missing Tooth Clause​

A clause in the dental insurance plan that will not cover any dental treatment that replaces a tooth that was extracted or missing prior to the date the insurance coverage started.

Example: A patient is missing a tooth before obtaining insurance and then wants to get an implant for the missing tooth. If the plan includes a missing tooth clause that excludes prior extractions, the implant will not be covered for that patient.

National Provider Identifier​

The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for healthcare providers who are covered under the law.

  • Type 1 is for the provider (NPI). This is the only type of NPI a provider will need if they receive payments in their name or under their Social Security number as a solo practitioner. For practices with multiple dentists, obtain a Type 1 NPI for each dentist.
  • Type 2 is for group practices (Organization NPI).

Incorporated dental practices or other business entities paid under their business or corporate name, or under their employer identification number (EIN).

Network​

An organization comprising a group of medical providers, in this case, dentists.

  • Status
    • In Network: When an insurance company partners with a provider, such as a doctor or dentist, that provider agrees to a negotiated — i.e., discounted — rate for services provided to the member. This provider is an in-network provider.
    • Out-of-Network: When a provider doesn’t partner with the insurance company, the insurer is charged the full price for their services, which in turn increases a patient’s expenses. This is an out-of-network provider.
  • Name
    • Name of the organization that is made up of a group of dentists. (i.e., PPO, Premier, DPPO, DPPO Advantage, etc.)

Plan Type​

Describes the plan and what type of benefits are provided. These include EPO, HMO, Indemnity, Medicaid, Medicare, POS, and PPO.

Policy Period​

The defined time frame during which an insurance policy is valid and provides coverage to the policyholder. A policy period can span multiple years if a subscriber holds the plan for multiple years.

Subscriber​

An insurance subscriber is essentially the same as a policyholder. Insurance subscribers are the individuals who pay for the policy's premiums or the person whose employer provides the policy as a benefit.

Waiting Period​

In some cases, a plan may require a waiting period before covering a specific treatment. Waiting Periods typically only apply to major procedures, such as crowns, implants, and onlays, with no waiting periods for periodic exams and X-rays.

For example, suppose the plan has a 4-month waiting period for root canals. If the plan coverage began on January 1, then the waiting period ends on May 1. After May 1, patients are eligible to use benefits for this treatment at any time. Some dental plans have no waiting period.