Insurance Terms: Glossary of Dental and Vision Definitions

Simply scroll down to find the dental insurance terms you are looking for or use the alphabetical navigation to help you sort through the terms. This glossary of dental and vision insurance terms and definitions will help you make informed decisions concerning your health plan.

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Access
The availability of care to a patient.

Actual Charge
The actual amount charged by a provider for services.

Adjudication
Processing a claim to determine proper payment.

Age Limit
Minimum and maximum ages below and above which a benefits insurer will not accept applications or may not renew policies.

Allowable Charges
The maximum dollar amount a benefits plan will pay for a procedure.

Amalgam
A silver alloy filling.

Analgesia
The reduction or elimination of pain.

Ancillary Services
Services, other than those a provider performs, such as laboratory work, X-rays, and anesthesia.

Anesthesia
See General Anesthesia, Intravenous Sedation / Analgesia, Local Anesthesia, Non-Intravenous Conscious Sedation, or Regional Anesthesia

Application
A signed statement a benefits insurer requests that is used to decide whether or not to issue a policy.

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Balance Billing
When subscribers are billed for the difference between what the insurer pays and the fee that the provider normally charges.

Benefits
The amount a benefits company will pay.

Benefit Booklet
A booklet or pamphlet given to the subscriber that contains a general explanation of the benefits. Also known as "Summary Plan Descriptions."

Benefit Plan
A plan that provides payments to covered individuals for services in return for a premium paid in advance. Such plans often include deductibles, coinsurance, and/or maximums.

Bilateral
Both the right and left sides.

Billed Claims
The amount submitted by a provider for services provided to a covered individual.

Bitewings
X-rays used to reveal several upper and lower teeth as patients bite down on the X-ray film.

Bleaching
A cosmetic dental procedure that whitens teeth using a bleaching solution.

Bonding
The white dental material that is applied to a tooth to change its shape and/or color. Bonding also refers to how a filling or some bridges are attached to teeth.

Bridge
See Fixed Partial Denture or Pontic

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Calendar Year
The period beginning January 1 through December 31 of the same year.

Cap
See Crown.

Capitation
Fees paid to providers based on the number of patients they serve on behalf of a benefits plan.

Caries
Tooth decay.

Carve Out
See Nonduplication of Benefits.

Cavity
Tooth decay, see Caries.

Cementation
Affixing an inlay, onlay, crown or bridge with a dental cement.

Certificate of Coverage
A description of the benefits included in a benefit insurer's plan. The certificate of coverage is required by state law and explains the coverage provided under the contract.

Certificate of Insurance
A statement of coverage that outlines members' benefits.

Claim
Information submitted by a provider or covered person for reimbursement for services or materials.
Claims Review
Review of a claim before reimbursement is made to the provider or subscriber.

Closed Panel
With a closed panel, patients are eligible to receive benefits only if services are provided by providers who have signed an agreement with the benefit plan to provide treatment to eligible patients.

COBRA
A law that requires employers to offer continued benefits coverage to employees who have had their benefits coverage terminated.

Coinsurance
A percentage of the costs of services a patient pays. This is a characteristic of indemnity insurance, POS, and PPO plans.

Composite
A tooth-colored filling.

Contract Provider
A provider who agrees to provide services under special terms, conditions, and reimbursement arrangements.

Contract Fee Schedule Plan
A benefit plan in which participating providers agree to accept set fees for treatment.

Contract Year
The period of time from the effective date of the contract to the expiration date of the contract.

Coordination of Benefits (COB)
The provision that limits benefits for members with multiple benefits plans.

Co-payment, Co-pay
A specific fee paid by the subscriber for a specific service.

Coverage
Benefits of a benefit plan.

Covered Entity
Under HIPAA, this is a health plan, a health care clearinghouse, or a health care provider who transmits any health information in electronic form in connection with a HIPAA transaction.

Covered Person
An individual who meets a health plan's eligibility requirements and for whom premium payments are paid.

Covered Expenses
Expenses incurred by a covered person who qualifies for reimbursement under the terms of a policy.

Covered Services
Services for which payment is provided under the terms of a policy.

Credentialing
Approving a provider to participate in a benefit plan.

Crown


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D.D.S., D.M.D.
Academic degrees awarded to graduates of United States dental schools.

Date of Service
The date that the service was provided.

Debridement
Removing foreign matter or dead tissue.

Decay
The decomposition of tooth structure.

Deductible
The amount of covered charges the member pays before benefits are paid.

Deductible Carry Over Credit
Charges applied to the deductible for services during the last months of a calendar year that may be used for the next year's deductible.

Dental Health Maintenance Organization (DHMO)
A legal entity that accepts responsibility and financial risk for providing specified services to members during a defined period of time at a fixed price. It is an organized system of care delivery that provides comprehensive care to enrollees through designated providers.

Dental Coverage
A plan that provides financial assistance for the expense of prevention, treatment, and care of dental disease.

Dental Prosthesis
An artificial device that replaces one or more missing teeth.

Denture
An artificial substitute for natural teeth and adjacent tissues.

Denture Base
The part of the denture that holds artificial teeth and fits over the gums.

Dependent
An individual who is eligible for benefits through a spouse, parent, or other family member.

DHMO
See Dental Health Maintenance Organization.

Digital X-Ray
X-rays that are captured in digital format instead of X-ray film and can be seen immediately on a computer screen after exposure.

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Effective Date
The date on which benefits under a policy begin.

Eligibility Date
The date on which an individual member becomes eligible to apply for benefits under the benefit plan.

Eligibility Period
A specified length of time, following the eligibility date during which an individual member will remain eligible to apply for benefits under a benefit plan without evidence of insurability.

Eligible Dependent
A dependent of a covered person (spouse, child, or other dependent) who meets all requirements specified in the contract to qualify for coverage and for whom premium payment is made.

Eligible Expenses
The lower of the maximum allowable charges or set service fees for dental or vision services and supplies that are covered under a benefit plan.

Endodontist
A dental specialist who limits his/her practice to treating disease and injuries of tooth pulp.

Enrollee
An individual covered by a benefit plan.

Enrollment Booklet
A booklet or pamphlet provided to the subscriber that contains a general explanation of the plan's benefits. Also known as "Summary Plan Descriptions."

EPO
See Exclusive Provider Organization.

Evaluation


Exclusions
Services not covered under a benefit program.

Exclusive Provider Organization (EPO)
People who belong to an EPO must receive their care from affiliated providers, and services rendered by unaffiliated providers are not reimbursed.

Expiration Date
The date on which the dental contract expires, also the date an individual ceases to be eligible for benefits.

Explanation of Benefits (EOB)
The statement sent to a subscriber by their benefits company listing services provided, amount billed, eligible expenses, and payment made by the company.

Extraction
The removal of a tooth or tooth parts.

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