Processing a claim through a series of edits to determine proper payment. Auto-adjudication is processing a claim without any human interaction.
The costs assumed by a managed care plan for administrative services such as claims processing, billing, and overhead costs.
The fees, on which program deductibles, maximums, and coinsurance percentage are based, that a dental program will reimburse a dentist for a service as defined by contract. This is the amount that can be charged back to patients. This is also referred to as the maximum plan allowance or maximum allowable charge. Dentists have agreed to accept a maximum plan allowance based on the agreements they have signed with Delta Dental. This does not apply to non-participating dentists.
The total fee that must be paid by the member company and the patient. Participating dentists have agreed to accept a maximum plan allowance based on agreements signed with Delta Dental. Non-participating dentists use the submitted amount.
Balance billing occurs when a participating dentist bills an enrollee for amounts disallowed by Delta Dental
that are also not allowed to be charged to the enrollee. Participating dentists agree to accept the fee approved by Delta Dental as payment in full. Dentists may not bill an eligible Delta Dental patient for any difference or balance between the Delta Dental approved fee and the submitted fee. Out-of-network (non-participating) dentists are not limited in the amount they may balance bill.
A person who is eligible to receive insurance benefits.
An overview of an enrollee’s dental benefit program, usually including co-payment percentages, deductibles, maximums, and non-covered services, often used at open enrollments. Also referred to as “benefit highlights.” See summary plan description and evidence of coverage.
The 12-month period to which each enrollee’s deductibles, maximums, and other plan provisions are applied. Start and end date may vary from those of a calendar year.
A per-member, monthly payment to a provider that covers contracted services and is paid in advance of its delivery. In essence, a provider agrees to provide specified services to plan members for this fixed, predetermined payment for a specified length of time (usually a year), regardless of how many times the member uses the services. See HMO and DeltaCare.
Delta Dental member companies include dental benefits carriers, dental carriers, health carriers, service corporations, and service plans. The majority of Delta Dental organizations are licensed as specialized health care service plans.
CDT codes (Current Dental Terminology)
Under HIPAA, the American Dental Association’s CDT codes are the required standard for electronic dental claims.
claim or claim form
Information submitted by a dentist or enrollee to establish that services were provided to an enrollee, from which processing for payment to the dentist or enrollee is made. A dentist is responsible for the accuracy of all information on a claim form. Claim forms can be submitted to carriers on paper or electronically.
The amount paid to Delta Dental by a group with an administrative services only (ASO) contract. An ASO
group insures its enrollees with its own funds, and must reimburse Delta Dental for claims that have been paid on its behalf.
The method by which an enrollee’s healthcare service claims are reviewed before reimbursement is made. The purpose of this monitoring system is to validate the appropriateness of the provided services and to be sure the
cost of the services is not excessive.
Arrangement in which enrollees must go to a network dentist to receive benefits. A capitation (HMO) program is an example of a closed panel program.
The Consolidated Omnibus Budget Reconciliation Act (COBRA) is federal legislation that requires employers to offer continued health insurance coverage to employees and their dependents who have had their health insurance coverage terminated. It allows enrollees, spouses, and children to pay to continue their health benefits coverage for up to 18 months after their coverage is terminated (or up to 29 months if the individual is disabled). For example, a spouse who would lose eligibility after divorcing a covered employee could decide to pay his/her own premium to continue group health coverage.
The percentage of the costs of services paid by the patient. This is a characteristic of indemnity insurance, POS,
and PPO plans. See copayment.
coordination of benefits (COB)
When a person is covered by more than one benefit plan (for example, a child who is covered by both parents’ programs), the two sets of benefits are coordinated so that no more than 100 percent of the total covered expense is paid. Non-duplication of benefits is a contract provision that further limits coverage. See dual coverage and non-duplication benefits.
The enrollee’s share of payment for a given service. The copayment is usually expressed as a percentage of the dentist’s fee, but can be expressed as the enrollee’s preset share of payment for a given service. See coinsurance.
Financing arrangement whereby the enrollee in a health plan must pay some of the costs to receive care.
Services for which payment is provided under the terms of the dental benefit contract.
Review of documentation pertaining to a dentist and his/her practice, including verification of licenses, specialty certification (if applicable), malpractice insurance, state and local licensing board actions, infection
control procedures, and Occupational Safety and Health Administration (OSHA) requirements.
DDS stands for Doctor of Dental Surgery. DMD stands for Doctor of Dental Medicine.
The total amount (usually expressed as an annual figure) enrollees must pay toward treatment before their health benefits are paid. The deductible plus the copayment and amount over the annual maximum are often referred to as the enrollee’s out-of-pocket costs. Under Delta Dental benefit plans, diagnostic and preventive services are often exempt from a deductible.
Delta Dental Plans Association (DDPA)
Delta Dental Plans Association is an organization of Delta Dental member companies in all 50 states, the District of Columbia, and Puerto Rico. Through its meetings, committees, documents, and other communications, DDPA provides the Delta Dental System with national guidelines and support.
dentist filed fees
A participating dentist’s submission of fees for procedures common to their practice and reported most frequently on dental claims.
Department of Health and Human Services (HHS)
A federal department that oversees the administration of HIPAA as well as other federally funded programs that provide services such as prenatal screening, immunization, child care, nutrition, exercise, and long-term care regulation.
Department of Managed Health Care (DMHC)
As nonprofit specialized health care service plans, most Delta Dental member companies are governed by their state’s Department of Managed Health Care and are subject to the requirements and regulations set by this government agency.
diagnostic and preventative procedures
In the standard client contract, these procedures include oral examinations, cleanings, x-rays, fluoride treatment, and space maintainers.
A denial by a health care payer for portions of the claimed amount. Examples would include coordination of benefits, services that are not covered, or amounts over the fee maximum.
When an enrollee has coverage under more than one benefit plan. The primary and secondary carriers coordinate the two plans so that the primary carrier pays its portion first and the secondary carrier may pay the remainder. See coordination of benefits and non-duplication benefits.
Dental services that are immediately required to relieve pain, swelling, or bleeding, or required to avoid jeopardizing the patient’s health.
The portion of the insurance premium paid by the employee.
Dental specialist who treats the root and nerve of the tooth.
A person covered under a Delta Dental plan. Enrollees includes both subscribers and their covered dependents. See subscriber.
explanation of benefits (EOB)
An industry term for the notice that enrollees receive after a claim is processed. The EOB provides information about the fees charged, what procedures were provided, and the enrollee’s payment portion.
A plan design in which the dentist is reimbursed a specified amount per service (as opposed to per enrollee, which is how an HMO works). See managed fee-for-service.
A comprehensive listing of fees used to reimburse providers on a fee-for-service basis.
General dentists provide a full range of dental services for the entire family.
Term used to describe a dental benefit customer or purchaser, usually an employer or a union/labor trust.
Heath Insurance Portability and Accountability Act of 1996 (HIPAA)
This federal initiative becomes effective in stages over several years. Title I of HIPAA was enacted to ensure that people can keep their health insurance when changing jobs. Title II of HIPAA requires adherence to coding and transmission standards for electronic health care transactions as well as to privacy and security requirements to protect health care information and anti-fraud measures. See the Administrative Simplification section of the Department of Health and Human Services’ website for more information at http://aspe.os.dhhs.gove/admnsimp/
HMO (health maintenance organization)
A method of health care delivery in which enrollees receive all treatment from the medical or dental office in which they are enrolled. The physician or dentist receives a single monthly payment from the benefits carrier for each enrolled patient, no matter how many services that patient receives. This type of benefit is also called capitation. See DeltaCare.
Term used to describe a participating dentist or a service provided by a participating dentist. See network.
Services that are limited or excluded from a dental benefit plan. The enrollee is usually responsible for the fee for services that are not benefits of the dental benefit plan. These services are called optional services.
maximum/ annual maximum/maximum benefit
The maximum payment Delta Dental will make within a given time period. Some plans have no maximum. Some maximums apply to the lifetime of the benefit plan; others apply to a particular time period (calendar year, benefit year, etc.) or to particular services (such as a separate maximum for orthodontic benefits).
A federal-state program that helps pay for health care for the economically disadvantaged, elderly, blind, or disabled as well as low-income families with children. A state determines eligibility and which health services are covered. The federal government reimburses a percentage of the state’s expenditures.
A federal health care insurance program for people aged 65 and over, and for the disabled. Eligibility is based mainly on eligibility for Social Security. Medicare helps pay charges for hospitalization, for stays in skilled nursing facilities, for physician’s charges, and for some associated health costs. There are limitations on the length of stay and type of care.
A group with subscribers in more than one state.
non-duplication of benefits
In dual coverage cases, some customers have a non-duplication of benefits contract provision. This term describes the way the secondary carrier calculates its portion of the payment. The secondary carrier calculates what it would have paid if it were the primary plan and subtracts what the other plan paid. If the primary payment was greater than or equal to what the secondary coverage would have paid, the secondary program will make no payment. See dual coverage.
Any dentist who does not have a contractual agreement with Delta Dental to provide dental services to enrollees of a Delta Dental benefit plan. See participating.
Dental specialist who diagnoses diseases of the mouth from the study of tissue samples.
Dental specialist who removes impacted teeth and repairs fractures of the jaw and other damage to the bone structure around the mouth.
Dental specialist who straightens or moves misaligned teeth and/or jaws, usually with braces.
Term used to describe a non-participating dentist or a service provided by a non-participating dentist. See
The portion of dental fees that the enrollee pays. Depending on the circumstances, it may include a copayment, a deductible, and any amount exceeding the plan’s maximum and optional services not covered by the plan.
participating dentist/Delta Dental dentist
These words refer to dentists who contract with Delta Dental and abide by certain administrative guidelines.
Dental specialist who generally limits treatment to children and teenagers.
Dental specialist who treats gums, tissue, and bone that support the teeth.
Provided upon the request of dentists, a preauthorization gives the guaranteed amount of how much of a proposed treatment plan will be covered under a patient’s dental program and what the patient’s out-of-pocket cost will be. The difference between a preauthorization and a predetermination is that with a preauthorization, the amount Delta Dental will pay is guaranteed as long as the preauthorized services are provided within the preauthorized period (usually 60 days). For DeltaCare, specialty care and out-of-network care must be preauthorized before the work can be provided.
Provided upon the request of dentists, a predetermination gives an estimate of how much of a proposed treatment plan will be covered under an enrollee’s dental program and what the enrollee’s out-of-pocket cost will be. Predeterminations generally apply to fee-for-service plans, not prepaid plans.
An example of a pre-existing condition is a tooth that was missing before the enrollee had coverage. Standard contracts do not exclude benefits for restoration of pre-existing conditions.
preferred provider organization (PPO)
A PPO is a fee-for-service program that allows enrollees to choose any dentist but provides financial incentives to choose lower-priced dentists who are part of the PPO network. Delta Dental’s PPO is called Delta Dental PPO.
A premium is the monthly payment customers make to Delta Dental for fully insured plans.
Dental specialist who replaces missing teeth with artificial materials, such as a bridge or denture.
A dentist or other practitioner, such as a dental hygienist.
A dentist who has received advanced training and is certified in one of the recognized dental specialties:
endodontics, orthodontics, oral surgery, pediatric dentistry, periodontics, and prosthodontics.
Subscribers are the persons counted in a group (generally employees or members of the group). Enrollees include both subscribers and their covered dependents. See enrollee.
table of allowance/schedule of allowance
A list of the maximum fees for each procedure that a particular program will pay.
Refers to a dental plan in which subscribers may choose to sign up for coverage and pay typically more than 50 percent of the cost of the plan.
Processing a claim through a series of edits to determine proper payment. Auto-adjudication is processing a claim without any human interaction.