| Term | Definition |
|---|
| Benefits | the amount that the insurance entity will pay for covered dental services described in their policy |
| Capitation | a dental provider gets paid a specified dollar amount, for a given time period, to take care of the dental needs of a specified group of people |
| Civillian Health and Medical Program of the Uniformed Services (CHAMPUS) | medical benefits for military personnel, dependents, and retired military |
| Claims Processing | the entire process of entering the procedures rendered until payment is collected or denial is determined |
| Commercial Insurance Plans | an insurance plan that operates for a profit |
| Contract | the insurance contract between the insurance entity and the group |
| Copayment | a portion of the cost of each service which is paid by the patient |
| Deductible | the amount the individual enrolled in the insurance plan must pay toward covered services before the insurance entity begins paying |
| Dental Claim | A claim for payment made by the patient for a dental procedure that was rendered |
| Dental Claim Form | the standard dental form utilized to file a claim or request authorization for a procedure |
| Dental Necessity | a service provided by a dental provider that has been determined as a generally acceptable dental practice for teh diagnosis and treatment of an individual |
| Early and Periodontic Screening, Diagnosis and Treatment (EPSDT) | persons under 21 years of age must be covered by Medicaid for medical, dental, and vision care |
| Exclusive Provider Agreement (EPA) | dental care providers contracts with an employer (eliminating a 3rd party) and negotiates the fees for services offered to the employer's employees |
| Explanation of benefits | a form sent to the pt and provider explaining the payment for procedures or denial of payment for procedures rendered |
| Fee Slip | form utilized by the dental provider that details the services rendered |
| Managed Care | refers to the integration of health care delivery and financing |
| Medicaid (title XIX) | monet from federal, state and local taxes pays bills for certain groups of people, including low-income, aged, blind, disabled, and member of families with disabled children |
| Medicare (title XVIII) | a federal insurance program from trust fund to pay medical bills of all people over 65 |
| Preexisting Condition | the condition of the mouth that exists prior to the pt being covered by an insurance entity |
| Premium | the monthly amount due to the insurance entity by the group or the individual |
| Procedure Number | the number given to a specific procedure as designated in the CODES ON DENTAL PROCEDURES AND NOMENCLATURE published by the ADA |
| Provider | a legally licensed DH or dentist who is operating within her scope of practice |
| Prepaid Group Practice | a large group of dental providers contract to groups of pts. |
| Single Procedure | a specific procedure designated by a specific code |
| Sound natural teeth | teeth that are either primary or permanent that have adequate hard and soft tissue support |
| State Children Health Insurance Program (SCHIP) | a federal program that was created by the federal goverment to cover individuals that have incomes too high to qualify for state medical assistance but cannot obtain private insurance. all states participate but some do not cover dental |
| Three Party System | the dental provider renders the service and a sponser of the pt pays for the service. insurence company or employer pays the dental provider for the service |
| Two Party System | the dental providers render the service and the pt pays the dental provider for the service |
| UCR (usual, customary, and reasonable fee) | the fee that reflects the average dental provider fee per service in the immediate local |
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