Insurance. 101
Annual Deductible
The annual deductible is a specific dollar amount that you must pay before dental benefit payments are paid to dental providers. The annual deductible is typically applied to Basic Services (Fillings, Extractions, Root Canals) and Major Services (Crowns). However, there are instances where the annual deductible also applies to Preventative Services (Dental Exams, Cleanings, and Sealants) for some dental insurance plans.
Out of Pocket
Your out-of-pocket is also a specific dollar amount that you pay after we have determined what your dental insurance will pay for a particular procedure/treatment. For example, should an zirconia crown be billed at $500 and covered by your dental insurance insurance at 80%, you’re responsible for the remaining 20% ($100), known as your out-of-pocket.
Non-Covered Services
Non-Covered Services are dental services that are not covered under your dental insurance plan.
Birthday Rule
The birthday rule applies when both parents and their children are enrolled in separate dental insurance plans. Should the father be born in January and the mother in February, then the father’s dental insurance plan would be considered the primary insurance and the mother’s dental insurance plan would be considered the secondary insurance independent of which parent is older.
Downgrading
Downgrading is when a dental insurance carrier pays for a less expensive procedure then the completed procedure. Fillings and crowns are often downgraded. Should you elect for a more expensive procedure, you will be responsible for the difference.
Calendar Year Max
The calendar year max is a specific dollar amount that you are given by your dental insurance carrier for a twelve-month period for dental services. This does not indicate, however, that you will have 100% coverage of dental services during that period.
Lifetime Max
The maximum amount a dental insurance carrier will pay over the course of a lifetime. It can apply to an individual and/or a family.
Dental Benefits
Dental benefits are broken down in three categories: Preventative, Basic and Major.
Preventative: Exams, Cleanings, Fluoride, Sealants, and Silver Diamine Fluoride.
Basic: Fillings, Extractions, Pulpotomies, and Root Canals
Major: Crowns
Secondary Insurance
Secondary insurance may pay for some services that are not covered under the primary insurance. However, the primary insurance will always pay first.
Dual Coverage
When a member and applicable dependents have coverage under two separate dental policies, they have dual coverage. The primary and secondary dental insurance carriers will coordinate to determine payment for dental services.
Coinsurance
Coinsurance is a percentage of the total fee for a particular service that the patient is responsible to pay. For example, a service may be paid by insurance at 80% and the patient would be responsible for the remaining 20% in that instance.
Explanation of Benefits (EOB)
An explanation of benefits (EOB) shows in detail the services that were rendered and the amount the insurance insurance carrier paid for those services under the enrolled plan. It is NOT a bill.
Benefit Year
A twelve-month period that a member’s dental plan is active.
Claim
The dental provider submits a claim to the patient’s insurance carrier to be paid for services that were rendered in accordance with the dental carriers fees for dental services.
Covered Service
A service that the dental carrier is contracted to pay a percentage of the fee.
Exclusions
Services that are not covered under the dental plan.
Fee Schedule
A list of charges for specific dental treatments and procedures.
Contracted Fee
The Contracted Fee is a fee that a dental provider has agreed to accept for members of a specific dental insurance group.
In-Network
A provider that is In-Network has agreed be part of a dental carriers network and accepts their fees for their services.
Out-Of-Network
A provider that is Out-Of-Network has NOT agreed to be part of a specific dental carrier. The patient is responsible for the usual and customary fees for an out of network provider.
Waiting Period
A period of time after the member has enrolled under the dental plan before the member is eligible to receive benefits for certain treatments and procedures. This typically applies to Major services such as Crowns.
Assignment of Benefits
When a member authorizes the dental insurance plan to forward payment to the dental provider for covered services.
Pre-Treatment Estimate
The Pre-Treatment estimate is a written estimate of benefits and payments available for a specific dental insurance policy for proposed treatment in accordance with the submitted treatment plan and contracted fee schedule. This can help a family be prepared financially for dental procedures and/or decide to proceed with the recommended treatment.
National Provider Identifier (NPI)
A unique identification number that is used to identify healthcare professionals in the United States.
Termination Date
A date that a member is no longer eligible to receive dental benefits.
Premium
A monthly, quarterly, or annual payment from the member to the insurance carrier to be eligible for dental benefits.
Open Enrollment
A set period in the year where individuals are capable of enrolling or making alterations to their dental insurance policy.
Limitations
Dental services that are not covered under your dental insurance. If you elect to receive services that are not covered under your dental plan, you will be responsible to pay the entire fee for that service.
Dependent
An individual that is covered under the dental plan, besides the primary member. This can be a child or spouse.