Dental insurance terms

Key dental insurance terms and definitions.

Eligibility and Benefits Terms

Insurances define benefits with the following properties:

  1. Coinsurance - What % of the total cost is covered by insurances?
  2. Maximum - Maximum amount insurances will cover for the year.
  3. Deductible - Dollar amount patients must pay first for covered services before insurances coverage kicks in.
  4. Frequency Limitation - Restriction set by insurance for the maximum number of services covered in a certain period of time.
  5. History - History of usage for a specific benefit, used in conjunction with Frequency Limitation to determine coverage.
  6. Age Limitation - Age restriction set by insurance for availability of coverage.
  7. Missing Tooth Clause - Whether or not dental insurance will cover the costs of replacing the tooth if the tooth fell out or was extracted before the current dental coverage started.
  8. Waiting Period - Length of time until full dental benefits begins.
  9. Effective date - The date coverage begins for a member. Waiting period countdowns begin with the effective date.
  10. Downgrades - When insurance companies elect to pay for the least expensive procedure if there is more than one acceptable option.
  11. Copayment - The amount the member is required to pay for services rendered.
  12. Coordination of benefits - Rules that determine what each plan will pay when a member has more than one active insurance plan.
  13. Fee schedule - A list of dollar amounts the dentist is contracted to charge the member if in network.
  14. 270/271 Eligibility Benefit Inquiry and Response - Electronic transactions used in the healthcare industry to request and retrieve a member's insurance coverage and benefits. Transactions are generally made to clearinghouses or directly to payer systems.
  15. EDI - Stands for Electronic Data Interchange, and refers to the structured data format used to make 270/271 transactions.
  16. Provider portal - Website provided by payer that provides tools for providers to access patient plan details, claims, and billing.