SITE MAP COMPANY RATINGS AGENT LOGIN ADMINISTRATOR

SERVICE CENTER

Glossary

A B C D E I M N O P R U

Adjudication: The formal process of making a decision on a claim or resolving a disputed claim in claims administration.
Benefit: The amount of money payable by a health or dental plan for the cost of covered services, as defined in the Certificate of Coverage.
Benefit Period: The maximum length of time for which benefits will be paid under the terms of the policy.
Claim: An itemized statement of health care services and their costs provided by a dentist, or other provider facility. Claims are submitted to the insurer for payment of the costs incurred by the covered person.
COBRA (Consolidated Omnibus Budget Reconciliation Act): A federal law which, among other things, requires employers to offer employees and their dependents who would otherwise lose their group health plan eligibility, continuation of coverage under the firm’s group plan. Employers are required to make health plans available for periods ranging from 18 to 36 months.
Coinsurance: A provision of a program by which the insured shares in the cost of covered services on a percentage basis. The health plan assumes only a certain percentage of the cost while the covered person pays the remainder.
Coordination of Benefits (COB): When the covered person is covered by another plan or plans, the benefits under the policy and the other Plan(s) will be coordinated so benefits from all sources do not exceed 100 percent of allowable expenses. This means one Plan pays its full benefits, then the other Plan(s) pay(s).
Co-payment (or co-pay): A specific payment by the covered person at the point of each health service visit. It does not accumulate like a deductible and is not subject to an out-of-pocket maximum.
Customary and Reasonable (C&R): See Usual, Customary, and Reasonable.
Deductible: The amount of out-of-pocket expenses that must be paid for health services by the covered person before the health plan benefit payment begins. This is usually based on a calendar year.
Dental Care: The evaluation, diagnosis, prevention, and/or treatment (nonsurgical, surgical or related procedures) of diseases, disorders, and/or conditions of the oral cavity, maxillofacial area, and/or the adjacent and associated structures and their impact on the human body; provided by a dentist, within the scope of his/her education, training and experience, in accordance with the ethics of the profession and applicable law.
Dependent: An individual other than a health plan subscriber who is eligible to receive health care services under the subscriber’s contract. Generally, dependents are limited to the subscriber’s spouse and minor children.
Effective Date: The date a policy, dental, or health plan contract goes into effect.
Exclusions: Specific conditions or circumstances listed in a health benefit contract or employee benefit plan for which the policy or plan will not provide benefit payments.
Explanation of Benefits (EOB): A statement sent by a health plan to a covered person who files a claim. The explanation of benefits (EOB) lists the services provided, the amount billed, and the payment made. The EOB statement also explains why a claim was or was not paid, and provide information about the individual’s rights of appeal.
I.D. Card/Identification Card: A card issued to a covered person, which allows the covered person to identify themselves or their covered dependent to a provider for health care services. Information on the card is used by the provider to help determine benefit levels and to prepare the bill/claim.
In-Network: Refers to the use of providers who participate in provider network. Use of a participating (in-network) provider may reduce the enrollee’s out-of-pocket expense.
Member: An individual or dependent enrolled in and covered by a health or dental plan.
Network: The dentists and other providers that a health or dental plan contracts with to provide care to its members.
Network Provider: The dentists and other providers that are in the network of the dental plan.
Non-Participating Provider: A provider that has not contracted with a health or dental plan to provide care services to covered persons.
Out-of-Network: The use of health care providers who have not contracted with the health or dental plan to provide services.
Out-of-Pocket Maximum: The amount which a covered person must pay for deductibles, coinsurance and copays in a defined time period (generally calendar year) before the health plan covers all remaining covered services at 100 percent up to the plan benefit maximum.
Participating Provider: The dentists and other providers that are in the network of the dental plan.
Plan Benefit Maximum: The maximum amount that a health plan will pay toward the cost of services incurred by an individual or family in a specified period, usually a calendar year.
Pre-Existing Condition: A physical and/or mental condition of an insured person that existed prior to the issuance of his or her insurance policy or that existed prior to issuance and for which treatment was received.
Preferred Provider Organization (PPO): A type of managed care plan which contracts with independent providers for negotiated discounted fees for services provided to covered persons.
Provider: An individual or organization that provides health and dental care services.
Provider Network: A set of providers contracted with a health plan to provide services to covered person(s).
Reasonable and Customary: See Usual, Customary and Reasonable.
Usual, Customary and Reasonable ( UCR): The usual fee is the fee usually charged for a given service by an individual provider to his or her private patient, that is, his or her own usual fee. The customary fee is the range of usual fees charged by providers of similar training and experience in an area. The reasonable fee is the fee that meets the two previous criteria or, in the opinion of the responsible medical or dental association’s review committee, is justifiable considering the special circumstances of the particular case in question.