Over time, we have found the process of using dental insurance or dental benefits can intimidate patients. We have put together this glossary of common insurance terms to help our patients better understand how their dental benefits work and the reimbursement process. If you hear our staff use a term that you do not understand, feel free to ask them to explain. Knowledge is power and Day & Night Family Dental wants you to get the most out of your hard earned dental benefits.
Annual Maximum The total dollar amount that an insurance plan will pay for dental care incurred by an individual enrollee or family (under a family plan) in a specified benefit period, typically a calendar year.
Balance Billing Dentist fees that the insured enrollee is billed for amounts above the enrollee’s portion of the coinsurance.
Claim/Claim Form A statement sent to an insurance carrier that lists the treatment performed, the date of that treatment and an itemization of associated costs; serves as the basis for payment of benefits.
Co-payment The part of the fee you owe the dentist before or after your insurance carrier has paid its portion. Day & Night Family Dental will help you estimate your co-payment at the time of service.
Coinsurance The enrollee’s share, expressed as a fixed percentage, of the insurance contract allowance. For example, a benefit that is paid at 80 percent by an insurance plan creates a 20 percent coinsurance obligation for the enrollee. Coinsurance applies after the enrollee meets a required deductible. Day & Night Family Dental will help you estimate your coinsurance payment prior to service.
Coordination of Benefits (COB) A process that insurance carriers use to determine the order of payment and amount each insurance carrier will pay when a person receives dental services that are covered by more than one insurance benefit plan.
Covered Services Services for which payment is provided under the terms of a dental insurance benefit contract.
Deductible A dollar amount that each enrollee (or cumulatively a family for family coverage) must pay for certain covered services before your insurance company begins paying benefits. The friendly staff at Day & Night Family Dental will help determine your deductible and co-pay amounts prior to treatment.
Diagnostic & Preventive Services A category of dental services in a fee-for-service dental insurance benefits contract that usually includes oral evaluations, routine cleanings, x-rays and fluoride treatments.
Dual Coverage When dental treatment for an enrollee is covered by more than one dental insurance benefits plan. When a patient has dual coverage, the friendly staff at Day & Night Family Dental can help sort through the responsibilities of each dental insurance benefit plan, helping the patient get the most out of their hard earned dental benefits.
Effective Date The date a dental benefits contract begins. Effective date may also be used to describe the date that benefits begin for a plan enrollee.
Eligible Enrollee An enrollee who has met the eligibility requirements under a dental benefit plan.
Eligibility The circumstances or conditions that define who and when a person may qualify to enroll in a plan and/or a specific category of covered services. These circumstances or conditions may include length of employment, job status, length of time an enrollee has been covered under the plan, dependency, child and student age limits, etc.
Enrollee A person who receives insurance benefits under a dental benefit contract (also known as “member”, “insured”, “covered person”, “beneficiary”).
Explanation of Benefits (EOB) An insurance statement notifying members/enrollees each time a dental claim is processed.
In-Network/Out-of-Network Services provided by a dentist that participates in a dental insurance, pre-paid or discount dental benefit plan (in-network) or does not participate in a dental insurance, pre-paid or discount dental benefit plan (out-of-network). Day & Night Family Dental does not have to be In-Network for you to see us. We accept most dental insurance as well as pre-paid and discount dental benefit plans and are happy to file claims on your behalf with your dental benefit provider.
Lifetime Maximum The cumulative dollar amount that an insurance plan will pay for dental care incurred by an individual enrollee or family (under a family plan) for the life of the enrollee or the plan. Lifetime maximums usually apply to specific services such as orthodontic treatment.
Limitations & Exclusions Dental insurance plans typically do not cover every dental procedure. Each insurance plan contains a list of conditions or circumstances that limit or exclude services from coverage. Limitations may be related to time or frequency (the number of procedures permitted during a stated period) — for example, no more than two cleanings in twelve months or one cleaning every six months. Exclusions are those dental services not covered by the insurance plan.
Limiting Age of Coverage The age at which a dependent covered by a dental insurance plan is no longer eligible to receive benefits; most dental insurance plans offer an extension of benefits beyond the limiting age of coverage to student and handicapped dependents.
Member A person who receives insurance benefits under a dental benefit contract (also known as “enrollee”, “insured”, “covered person”, “beneficiary”).
Out-of-Pocket Costs Any amount the enrollee is responsible for paying, such as coinsurance or copayments, deductibles, and costs above the annual maximum. The friendly staff at Day & Night Family Dental will help determine you’re out-of-pocket costs prior to treatment.
Preauthorization An insurance requirement that recommended treatment must first be approved by the plan before the treatment is rendered in order for the plan to pay benefits for those services. As Day & Night Family Dental takes most dental insurance, prepaid and discount dental benefit plans, we can help you determine which procedures or treatments require preauthorization and secure the necessary approvals on your behalf.
Preventive Services The dental procedures concerned with the prevention of dental diseases by protective and educational measures; may include exam, cleanings, x-rays and fluoride. Preventive services are the cornerstone of a healthy and beautiful smile and with Day & Night Family Dental’s convenient extended and weekend hours, scheduling an appointment for preventive services could not be easier. Call Day & Night Family Dental and schedule your appointment for a professional cleaning and comprehensive dental exam today.
Provider The dentist or specialist.
Subscriber An insured, member or enrollee.
Third-Party Provider An insurance company that pays all or a part of the cost of dental treatment.
Usual Fee The amount commonly charged for a particular service by an insurance provider.
Waiting Period A stated period of time that a person must be enrolled in an insurance benefit plan before being eligible for benefits or for a specific category of benefits.