Decoding Dental Insurance Terms

The definitions below may vary by state. Please review your policy carefully.

A

Accepted Fee

The amount the attending Provider agrees to accept as payment in full for services rendered.

Affordable Care Act/ACA

The ACA is the comprehensive health care reform law, enacted in March 2010. Provisions of the ACA ensure Americans access to reasonably priced, comprehensive health insurance.

B

Benefit Waiting Period
The period of time of continuous enrollment that an Enrollee must complete before certain dental procedures become covered benefits.
Benefits (In-Network or Out-of-Network)

The amounts that Dentegra will pay for dental services under this Policy. In-Network Benefits are those covered by this Policy and performed by a Dentegra Provider. Out-of-Network Benefits are those covered by this Policy but performed by a Non-Dentegra Provider.

C

Calendar Year

The period of time beginning on January 1st and ending on December 31st.

Claim Form

The standard form used to file a claim or request a Pre-Treatment Estimate.

D

Deductible

A dollar amount that an Enrollee and/or the Enrollee’s family (for family coverage) must pay for certain covered services before Dentegra begins paying benefits.

Dentegra PPO Dentist* (Dentegra Dentist)

A Provider who contracts with Dentegra and agrees to accept the Dentegra Contracted Fee as payment in full for services provided under a PPO plan. A Dentegra Provider also agrees to comply with Dentegra’s administrative guidelines.

Dentegra PPO Provider’s Contracted Fee (Dentegra Provider Contracted Fee)

The fee for each Single Procedure that a Dentegra Provider has contractually agreed to accept as payment in full for treating Enrollees.

Dependent Enrollee

An Eligible Dependent enrolled to receive Benefits.

E

Effective Date

The date the plan starts. This date is given in your Benefits Summary.

Eligible Dependent
A dependent of the Primary Enrollee or domestic partner eligible for Benefits.
Enrollee

An individual who made application for this dental Policy (“Primary Enrollee”) or an Eligible Dependent (“Dependent Enrollee”) enrolled to receive Benefits; may also be referred to as “Patient”.

Exchange/Exchange Marketplace/Health Care Exchange

An Exchange is a state or federally-facilitated insurance marketplace where individuals and businesses can compare and purchase qualified health and dental plans.

H

Health and Human Services/HHS/U.S. Department of Health and Human Services/CMS

This is the federal agency that oversees implementation of the Affordable Care Act.

M

Maximum Contract Allowance

The reimbursement under the Enrollee’s benefit plan against which Dentegra calculates its payment and the Enrollee’s financial obligation. Subject to adjustment for extreme difficulty or unusual circumstances, the Maximum Contract Allowance for services provided by: 1) a Dentegra Provider is the lesser of the Submitted Fee or the Dentegra Provider’s Contracted Fee; or 2) a Non-Dentegra Provider is the lesser of the Submitted Fee or the Dentegra Provider’s Contracted Fee for a Dentegra Provider in the same geographic area.

N

Non-Dentegra Provider

A Provider who is not a Dentegra Provider, is not contractually bound to abide by Dentegra’s administrative guidelines and has not agreed to accept the Dentegra Contracted Fees.

O

Open Enrollment

The time period in which individuals and businesses may enroll in plans through their state or federal marketplace.

P

Patient Pays

Enrollee’s financial obligation for services calculated as the difference between the amount shown as the Accepted Fee and the portion shown as “Dentegra Pays” on the claims statement when a claim is processed.

Policy

This contract of insurance issued and delivered to the Enrollee. It includes the application, any attached amendments, and any appendices.

Policy Benefit Level

The percentage of Maximum Contract Allowance that Dentegra will pay after the Deductible has been satisfied.

Policy Term

The period during which the Policy is in effect.

Policy Year

The 12 months starting on the Effective Date and each subsequent 12- month period thereafter.

Pre-Treatment Estimate

An estimation of the allowable Benefits under this Policy for the services proposed, assuming the person is an eligible Enrollee.

Premium

The amount payable by the Enrollee as provided in the Benefits Summary.

Primary Enrollee

The individual insured in this plan to receive Benefits.

Procedure Code
The Current Dental Terminology (CDT)© number assigned to a Single Procedure by the American Dental Association.
Program Allowance

The amount determined by a set percentile level of all charges for such services by Providers with similar professional standing in the same geographical area.

Provider
A person licensed to practice dentistry when and where services are performed. A Provider shall also include a dental partnership, dental professional corporation or dental clinic.

S

Single Procedure

A dental procedure that is assigned a separate CDT© number.

Small Business Health Insurance Options Program/SHOP

SHOP is each state’s exchange marketplace for small businesses.

Stand-alone

A stand-alone plan refers to benefits that are offered and may be purchased separately from other coverage such as medical.

Submitted Fee

The amount that the Provider bills and enters on a claim for a specific procedure.