Insurance Terminology

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ACCREDITATION - a process of gauging the performance of organizations against a set of agreed upon standards or measures. 

CAPITATION - a reimbursement methodology used in DHMOs where dentists provide covered dental services to members on a contract basis in return for a periodic per-capita payment. A member may pay a deductible, co-payment, or any amount exceeding specific plan maximum allowances or coverage levels. 

CLAIMS REVIEW - the process of reviewing submitted documentation for payment of benefits under the dental benefits policy. 

CLOSED PANEL - Offers a limited number of facilities, and a limited number of dentists from whom care MUST be obtained.

COMPLAINT(s) - A complaint is a written (or verbal) communication primarily expressing a disagreement or grievance concerning treatment or an apparent violation of a policy provision, contract provision, state rule or statute. 

CREDENTIALING - a process of review of information collected on a specific dental provider to determine participation in a network. Specific criteria and prerequisites may be applied to both determine initial admission and ongoing participation in the dental plan. 

DENTAL HEALTH MAINTENANCE ORGANIZATION “DHMO” (Also referred to as Capitation Plans or Prepaid Dental Plans): - A legal entity that accepts responsibility and financial risk for providing specific services to a defined population through a network of dentists that are usually paid monthly on a fixed per capita basis for each individual or family that is assigned to their dental office. Payment is not based upon the number or type of services rendered. 

NETWORK BASED DENTAL PLAN - A range of dental benefit products that utilize a network of dentists to deliver benefits including a DHMO, a DPPO, a dental referral plan. 

DENTAL PREFERRED PROVIDER ORGANIZATION “DPPO” - A Dental Plan with a network of dentists who have agreed to accept a specific level of payment for covered services. Reimbursement is on a fee-for-service basis. 

DENTAL REFERRAL PLAN “DRP” - A dental plan that arranges for individuals to have access to a panel of dentists that have agreed to provide services for the amount listed in a Fee Schedule. No payment is made from the plan to the dentist; dentists are paid by the enrollee. 

ENCOUNTER - Contact between a dental plan enrollee and a provider of dental care. 

ENROLLEE - An individual enrolled in a dental plan, including both members and covered dependents. 

ENROLLMENT - The number of enrollees subscribed in a dental plan. 

EXCLUSIVE PROVIDER ORGANIZATION. “EPO” - A Dental Plan that requires the member to use a participating dentist to receive benefits. No benefits are provided when a patient goes to a non-participating Dentist. 

FEE-FOR-SERVICE - The dentist receives a fee for each service provided. 

INDEMNITY - Indemnity benefits are expressed as a covered fee-for-service. This coverage allows patients to choose their own dentist. Limits and co-payments are set according to the level of coverage purchased by the employer or union. 

MANAGED DENTAL CARE - Dental Plans designed to manage the cost and quality of dental care through the use of various delivery systems and reimbursement models. 

MANAGED DENTAL PLAN - Dental Plan designed to manage the cost and quality of dental care using various delivery systems and reimbursement models. 

MEMBER MONTHS - A data term meaning the actual number of members a dental HMO had in a particular month; it is used on a cumulative basis as a divisor into summary of operations figures in order to derive a per member per month (pmpm) amount. 

NETWORK - The providers that an HMO, PPO, or other managed care network plan has selected and contracted with to care for its members. 

OUT-OF-NETWORK - Services rendered by providers other than those who have contracted to provide care. Unless pre-approved, services are generally not reimbursable. 

PAYMENT DIFFERENTIAL - Payment for services is less if member goes to a non-participating dentist. 

PMPM - Abbreviation for Per Member Per Month. 

POINT OF SERVICE “POS” - A Fee-for-Service Dental Plan with an out of Network option for DHMO or PPO participants. Generally benefits are reduced and/or reimbursement is based on a low Table of Allowances. 

PRACTICE GUIDELINES - Carefully developed information on diagnosing and treating specific dental conditions. Practice guidelines, usually based on clinical literature and expert consensus, are designed to help dentists and patients make decisions, and to help a dental health plan evaluate appropriateness and dental necessity of care. 

PREFERRED PROVIDER ORGANIZATION (PPO) - A group of dentists who contract with an insurance company to provide care at discounted fees. (”Preferred” refers to a dentist who has contractually agreed to provide services at discounted fees.)

PREVENTIVE CARE - Care designed to prevent disease altogether, to detect and treat it early, or to manage its course most effectively. Examples of preventive care include fluoride treatments, sealants, and examinations. 

PROVIDER - Any dental practitioner who is licensed or otherwise authorized to deliver (provide) dental services in any state of United States. 

QIC (Quality Improvement Committee) — The organizational entity responsible for quality functions in a dental plan including oversight of the Quality Improvement Plan. 

QIP (Quality Improvement Plan) - A written document with specific goals and objectives to continuously monitor and improve the quality of clinical and non-clinical services in a dental plan. 

SPECIALIST - A dentist or other health professional whose training and expertise are in a specific area of dentistry. Recognized clinical specialties in dentistry are: endodontists, oral and maxillofacial surgeons, oral patholigists, orthodontists, pediatric dentists, periodontists, prosthodontists and public health dentists. 

STANDARD - A requirement to be met in attaining accreditation. 

STATISTICALLY-BASED UTILIZATION REVIEW - A system that examines the distribution of treatment procedures based on claims information and in order to be reasonably reliable, the application of such claims analyses of specific dentists should include data on type of practice, dentist’s experience, socioeconomic characteristics, and geographic location. 

TABLE OF ALLOWANCES - Assigns a specific dollar to each dental procedure.

UTILIZATION - The extent to which the members of a covered group use a program over a stated period of time; specifically measured as a percentage determined by dividing the number of covered individuals who submitted one or more claims by the total number of covered individuals. 

An expression of the number and types of services used by the members of a covered group over a specified period of time.

UTILIZATION MANAGEMENT - Based upon the information provided by utilization review and other quality measures, management techniques applied to achieve care delivery goals of the dental plan. 

UTILIZATION REVIEW - A statistically based system that examines the distribution of treatment procedures based on claims or encounter information. In order to be reasonably reliable, the application of such claims analyses of specific dentists should include data on type of practice, dentist’s experience, socioeconomic characteristics, and geographic location.