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Test your basic knowledge |
Dental Insurance Vocab
Start Test
Study First
Subjects
:
health-sciences
,
dentistry
Instructions:
Answer 50 questions in 15 minutes.
If you are not ready to take this test, you can
study here
.
Match each statement with the correct term.
Don't refresh. All questions and answers are randomly picked and ordered every time you load a test.
This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.
1. Date an individual and/or dependents become eligible for benefits under a dental benefits contract.
Effective Date
Claimant
Direct Reimbursement
Preferred provider organization (PPO)
2. Unique identification number. NPI part of HIPAA
National Provider Identifier (NPI)
Exclusions
Assignment of Benefits
Deductible
3. Date on which the dental benefits or contract expires or date an individual ceases to be eligible for benefits.
Primary Carrier
Balance Billing
Expiration Date
Claim Form
4. Amount of dental expenses a covered person must pay before the dental plan benefits begin.
Medicaid
Direct Reimbursement
Deductible
Closed Panel System
5. Paper form used to request payment or predetermination for patients covered by a dental benefits program.
Deductible
Open Panel System
Effective Date
Claim Form
6. Benefits delivery system in which a dentist contracts with the programs's sponsor or administrator to provide all or most of the dental services covered under the program in return for a fixed monthly payment per covered person. Also called a DHMO (d
Open Panel System
Claimant
Capitation
Benefit year
7. Fee a dentist most frequently charges for a given dental service.
Copayment
Usual fee
Allowed amount
Cafeteria Plan
8. Dental benefits program in which a dentists are paid for each covered service rendered to an eligible enrollee.
Maximum allowable benefit (MAB)
Birthday Rule
Reimbursement
Fee for service plan
9. Reporting a more complex or more expensive procedure that was actually performed. Fraudulent.
Preexisting condition
Overcoding
Assignment of Benefits
Primary Carrier
10. Dental services that's payable under the terms of the benefit program.
Primary Carrier
Covered services
Exclusions
16. Current Dental Terminology (CDT)
11. Health care coverage system which employers offer a list of options for health care benefits.
Cafeteria Plan
Medicaid
Open Panel System
Usual fee
12. Reference manual by the ADA that includes the Codes on Dental Procedures and Nomenclature and other instructions tools for reporting dental services to dental benefits plan and administrators.
25. Exclusive Provider Organization (EPO) plan
Reimbursement
Reasonable and customary (R&C) plan
16. Current Dental Terminology (CDT)
13. Organization that bears the financial risk for the cost of defined categories or services for a defined group of policy holders or beneficiaries.
Insurer
Preferred provider organization (PPO)
Open enrollment
Covered services
14. Person who is eligible for benefits under a dental benefits contract; AKA member - insured individual - participant - beneficiary.
HIPAA
25. Exclusive Provider Organization (EPO) plan
Enrollee
Reasonable and customary (R&C) plan
15. Dental benefits program that allows 1) enrollees to receive dental treatment from any licensed dentist; 2) licensed dentist to participate; and 3) payment of benefits to either the enrollee or the dentist.
Primary Carrier
Subscriber
Allowed amount
Open Panel System
16. Dental services that are not covered under a dental benefits program--excluded from plan
Exclusions
Fee for service plan
Assignment of Benefits
Approved Services
17. Payment made by a benefit carrier or third party payer to an enrollee or to a dentist on behalf of the enrollee as repayment of fees charged.
Fee Schedule
Reimbursement
Open Panel System
Claim Form
18. Treatment plan submitted to the benefit carrier for review and estimate of payment before services are rendered.
Predetermination
HIPAA
Reasonable and customary (R&C) plan
Claimant
19. Consolidated omnibus budget reconciliation act which allows a person to temporarily maintain insurance coverage even if he/she loses job.
Predetermination
Subscriber
Primary Carrier
COBRA
20. Restrictions stated in a dental benefits contract that limit the scope of coverage.
National Provider Identifier (NPI)
Benefit year
Primary Carrier
Limitations
21. 12 month period of the dental contract (not always a calendar year)
Benefit year
COBRA
16. Current Dental Terminology (CDT)
Benefit administrator
22. Benefit carrier that has initial responsibility for benefit payment when a patient is covered by tow or more carriers.
Allowed amount
Primary Carrier
Maximum allowable benefit (MAB)
Cafeteria Plan
23. Dental benefits program in which participating dentists agree to a discounted fee schedule for services rendered to patients.
Maximum allowable benefit (MAB)
Overcoding
Preferred provider organization (PPO)
Benefit year
24. Detailed statement of a processed claim showing the patient - provider - procedure codes - date of service - the carrier's payment - and the patient's copayment.
Exclusions
Claim Form
27. Explanation of benefits EOB
Direct Billing
25. Fee for service dental benefits program in which payment of benefits is based on reasonable and customary fee criteria.
Dependents
Reasonable and customary (R&C) plan
Benefit year
Closed Panel System
26. Period between employment or enrollment in a dental program and the date the enrollee became eligible for benefits.
Benefit year
Premium
Waiting period
Dependents
27. Amount charged by a dental benefits carrier for coverage.
Usual fee
Insurer
Premium
Closed Panel System
28. Individuals - such as spouse and children - who are legally and contractually eligible for benefits under a subscriber's dental benefits contract.
Copayment
Dependents
COBRA
Predetermination
29. Fee for service/services determined to be representative of the fees charged by dentist in a specific region or geographical area.
Customary fee
Copayment
Assignment of Benefits
Claimant
30. Dental benefits program in Which benefits are provided only if care is rendered by institutional and professional providers with whom the plan contracts.
Direct Billing
Covered services
25. Exclusive Provider Organization (EPO) plan
Birthday Rule
31. Maximum dollar amount the benefit carrier allows for each dental procedure
Allowed amount
Fee for service plan
Waiting period
Maximum allowable benefit (MAB)
32. Employer's or organization's self funded program for reimbursing covered individuals based on a percentage of the amount spent for dental care.
Preferred provider organization (PPO)
Direct Reimbursement
HIPAA
Claimant
33. Amount or percentage of the dentist's fee that the patient is obligated to pay.
Premium
Overcoding
Dependents
Copayment
34. Federal Law intended to improve access to health insurance - limit fraud and abused - and control administrative costs.
27. Explanation of benefits EOB
Benefit year
Dependents
HIPAA
35. List of charges established by or agreed to by a dentist for specific dental services listed by ADA procedure codes.
Fee Schedule
Cafeteria Plan
Deductible
Usual fee
36. Requiring payment in full from the patient/responsible party for all services rendered.
16. Current Dental Terminology (CDT)
Insurer
Direct Billing
Reasonable and customary (R&C) plan
37. Dental benefits program in which enrollees can receive benefits only when services are provided by dentists who have signed an agreement with the benefit plan to provide treatment to eligible patients.
Closed Panel System
Allowed amount
Assignment of Benefits
Predetermination
38. Method of determining the primary carrier for dependent children who are covered more than one dental plan. With this method - the primary payer is the parent with the earlier date of birth by month and day - without regard to the year of birth.
Direct Billing
Open Panel System
Birthday Rule
16. Current Dental Terminology (CDT)
39. Period during which employees or group members can enroll in health care programs.
Approved Services
Open enrollment
Direct Reimbursement
Insurer
40. Services covered by a benefit plan. Payment for these services may be subject to plan maximums - limitations - and deductibles
Approved Services
Exclusions
COBRA
Overcoding
41. Dentist who does not have a contract agreement with benefits carrier.
Effective Date
Direct Billing
Claim Form
Nonparticipating dentist
42. Person or company who manages or directs a dental benefits program on behalf of the program's sponsor
COBRA
Customary fee
Premium
Benefit administrator
43. Federal assistance program; provides payment for medical care from the federal government.
Claim Form
Predetermination
Medicaid
Fee for service plan
44. Authorization by the enrollee/patient for the dental benefits carrier to make payment for covered services directly to the treating dentist
Open Panel System
Covered services
Subscriber
Assignment of Benefits
45. Dental benefits program that lists an assigned amount payable for each covered service; generally amount is below the average fee charged by dentists- AKA schedule of allowance.
Claimant
Dependents
Capitation
Table of allowance plan
46. Requiring the patient to pay any difference between the dentist's actual fee and the amount reimbursed by the benefits carrier(insurance company) - in addition to any co-payment - deductible - or maximum.
Balance Billing
Reasonable and customary (R&C) plan
Table of allowance plan
Preexisting condition
47. Oral health condition that existed before a person enrolled in a dental program.
Preexisting condition
Effective Date
Approved Services
Overcoding
48. Employee or participant who is certified by the company who receives benefit coverage.
Table of allowance plan
Maximum allowable benefit (MAB)
Subscriber
HIPAA
49. Highest total dollar amount a dental benefits program pays toward the cost of dental care incurred by an individual or family in a specified period such as a calendar year - a contract year or lifetime.
Customary fee
Birthday Rule
Maximum allowable benefit (MAB)
Cafeteria Plan
50. Person who files a claim for reimbursement of covered costs (the dentist & practice)
Reimbursement
Claimant
Usual fee
Fee for service plan