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Dental Insurance Vocab

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. Person who files a claim for reimbursement of covered costs (the dentist & practice)
Fee for service plan
Covered services
Waiting period
Claimant

2. Dental benefits program in which a dentists are paid for each covered service rendered to an eligible enrollee.
Fee for service plan
Primary Carrier
Direct Billing
COBRA

3. Person who is eligible for benefits under a dental benefits contract; AKA member - insured individual - participant - beneficiary.
Closed Panel System
Enrollee
Direct Billing
Customary fee

4. Dental benefits program in Which benefits are provided only if care is rendered by institutional and professional providers with whom the plan contracts.
Open enrollment
HIPAA
25. Exclusive Provider Organization (EPO) plan
Benefit year

5. 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.
Insurer
16. Current Dental Terminology (CDT)
Maximum allowable benefit (MAB)
Preferred provider organization (PPO)

6. 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.
Fee Schedule
Premium
Maximum allowable benefit (MAB)
Open Panel System

7. Employee or participant who is certified by the company who receives benefit coverage.
Subscriber
Table of allowance plan
Preexisting condition
Expiration Date

8. 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.
Table of allowance plan
27. Explanation of benefits EOB
Direct Reimbursement
Nonparticipating dentist

9. Detailed statement of a processed claim showing the patient - provider - procedure codes - date of service - the carrier's payment - and the patient's copayment.
Preferred provider organization (PPO)
Claimant
Enrollee
27. Explanation of benefits EOB

10. Dental benefits program in which participating dentists agree to a discounted fee schedule for services rendered to patients.
Copayment
Dependents
Preferred provider organization (PPO)
Subscriber

11. 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.
Preexisting condition
Balance Billing
Maximum allowable benefit (MAB)
COBRA

12. Employer's or organization's self funded program for reimbursing covered individuals based on a percentage of the amount spent for dental care.
Direct Reimbursement
Fee Schedule
Expiration Date
Enrollee

13. 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.
Premium
Birthday Rule
Reimbursement
Usual fee

14. 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
Dependents
Direct Billing
Deductible

15. Organization that bears the financial risk for the cost of defined categories or services for a defined group of policy holders or beneficiaries.
Insurer
27. Explanation of benefits EOB
Reimbursement
Limitations

16. Federal Law intended to improve access to health insurance - limit fraud and abused - and control administrative costs.
HIPAA
Deductible
Allowed amount
Insurer

17. Fee for service/services determined to be representative of the fees charged by dentist in a specific region or geographical area.
Fee for service plan
Deductible
Table of allowance plan
Customary fee

18. Maximum dollar amount the benefit carrier allows for each dental procedure
National Provider Identifier (NPI)
16. Current Dental Terminology (CDT)
Nonparticipating dentist
Allowed amount

19. Services covered by a benefit plan. Payment for these services may be subject to plan maximums - limitations - and deductibles
Effective Date
Balance Billing
Preferred provider organization (PPO)
Approved Services

20. Oral health condition that existed before a person enrolled in a dental program.
Closed Panel System
Exclusions
Premium
Preexisting condition

21. Health care coverage system which employers offer a list of options for health care benefits.
Cafeteria Plan
Deductible
Preferred provider organization (PPO)
Approved Services

22. Consolidated omnibus budget reconciliation act which allows a person to temporarily maintain insurance coverage even if he/she loses job.
Maximum allowable benefit (MAB)
COBRA
Dependents
Assignment of Benefits

23. Fee a dentist most frequently charges for a given dental service.
COBRA
Usual fee
Assignment of Benefits
16. Current Dental Terminology (CDT)

24. Fee for service dental benefits program in which payment of benefits is based on reasonable and customary fee criteria.
Reasonable and customary (R&C) plan
Expiration Date
Preferred provider organization (PPO)
HIPAA

25. List of charges established by or agreed to by a dentist for specific dental services listed by ADA procedure codes.
Benefit year
Fee Schedule
16. Current Dental Terminology (CDT)
Nonparticipating dentist

26. Dental services that's payable under the terms of the benefit program.
Usual fee
Covered services
Insurer
Claimant

27. Person or company who manages or directs a dental benefits program on behalf of the program's sponsor
Assignment of Benefits
16. Current Dental Terminology (CDT)
Primary Carrier
Benefit administrator

28. Paper form used to request payment or predetermination for patients covered by a dental benefits program.
Claim Form
Direct Billing
Open Panel System
Direct Reimbursement

29. Date an individual and/or dependents become eligible for benefits under a dental benefits contract.
Reimbursement
Fee for service plan
Effective Date
Copayment

30. Individuals - such as spouse and children - who are legally and contractually eligible for benefits under a subscriber's dental benefits contract.
Insurer
Customary fee
Reasonable and customary (R&C) plan
Dependents

31. Amount or percentage of the dentist's fee that the patient is obligated to pay.
Covered services
Maximum allowable benefit (MAB)
Copayment
Subscriber

32. Requiring payment in full from the patient/responsible party for all services rendered.
16. Current Dental Terminology (CDT)
Open Panel System
Direct Billing
Claimant

33. 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
Effective Date
Allowed amount
Capitation
Closed Panel System

34. Restrictions stated in a dental benefits contract that limit the scope of coverage.
Direct Reimbursement
Customary fee
Limitations
Covered services

35. Reporting a more complex or more expensive procedure that was actually performed. Fraudulent.
Overcoding
27. Explanation of benefits EOB
Usual fee
Limitations

36. Dental services that are not covered under a dental benefits program--excluded from plan
27. Explanation of benefits EOB
Expiration Date
Exclusions
Benefit administrator

37. Treatment plan submitted to the benefit carrier for review and estimate of payment before services are rendered.
Expiration Date
Medicaid
Predetermination
Covered services

38. Date on which the dental benefits or contract expires or date an individual ceases to be eligible for benefits.
Insurer
Expiration Date
Open enrollment
Reasonable and customary (R&C) plan

39. Amount of dental expenses a covered person must pay before the dental plan benefits begin.
Reasonable and customary (R&C) plan
Effective Date
Deductible
Open enrollment

40. Period during which employees or group members can enroll in health care programs.
Cafeteria Plan
Birthday Rule
Open enrollment
Table of allowance plan

41. 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.
16. Current Dental Terminology (CDT)
27. Explanation of benefits EOB
Fee for service plan
Claim Form

42. Period between employment or enrollment in a dental program and the date the enrollee became eligible for benefits.
Assignment of Benefits
COBRA
Waiting period
Enrollee

43. Benefit carrier that has initial responsibility for benefit payment when a patient is covered by tow or more carriers.
Primary Carrier
Table of allowance plan
Subscriber
Overcoding

44. Federal assistance program; provides payment for medical care from the federal government.
Dependents
Medicaid
Birthday Rule
16. Current Dental Terminology (CDT)

45. Dentist who does not have a contract agreement with benefits carrier.
Reasonable and customary (R&C) plan
Nonparticipating dentist
Primary Carrier
16. Current Dental Terminology (CDT)

46. Unique identification number. NPI part of HIPAA
Predetermination
Reimbursement
Fee for service plan
National Provider Identifier (NPI)

47. Authorization by the enrollee/patient for the dental benefits carrier to make payment for covered services directly to the treating dentist
Assignment of Benefits
Approved Services
Covered services
Table of allowance plan

48. Amount charged by a dental benefits carrier for coverage.
Open Panel System
Fee Schedule
Premium
Preexisting condition

49. 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.
Limitations
Cafeteria Plan
Reimbursement
Deductible

50. 12 month period of the dental contract (not always a calendar year)
Benefit year
Allowed amount
Preferred provider organization (PPO)
Overcoding