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Dental Insurance Vocab

  • Answer 50 questions in 15 minutes.
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  • Match each statement with the correct term.
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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. Organization that bears the financial risk for the cost of defined categories or services for a defined group of policy holders or beneficiaries.

2. Dental benefits program in which a dentists are paid for each covered service rendered to an eligible enrollee.

3. Federal Law intended to improve access to health insurance - limit fraud and abused - and control administrative costs.

4. Services covered by a benefit plan. Payment for these services may be subject to plan maximums - limitations - and deductibles

5. 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.

6. Date an individual and/or dependents become eligible for benefits under a dental benefits contract.

7. Health care coverage system which employers offer a list of options for health care benefits.

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.

9. Treatment plan submitted to the benefit carrier for review and estimate of payment before services are rendered.

10. 12 month period of the dental contract (not always a calendar year)

11. Paper form used to request payment or predetermination for patients covered by a dental benefits program.

12. Amount charged by a dental benefits carrier for coverage.

13. Period between employment or enrollment in a dental program and the date the enrollee became eligible for benefits.

14. 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.

15. Amount or percentage of the dentist's fee that the patient is obligated to pay.

16. 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

17. Person who files a claim for reimbursement of covered costs (the dentist & practice)

18. Requiring payment in full from the patient/responsible party for all services rendered.

19. 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.

20. List of charges established by or agreed to by a dentist for specific dental services listed by ADA procedure codes.

21. Oral health condition that existed before a person enrolled in a dental program.

22. Date on which the dental benefits or contract expires or date an individual ceases to be eligible for benefits.

23. Employer's or organization's self funded program for reimbursing covered individuals based on a percentage of the amount spent for dental care.

24. Employee or participant who is certified by the company who receives benefit coverage.

25. Person who is eligible for benefits under a dental benefits contract; AKA member - insured individual - participant - beneficiary.

26. Dental benefits program in which participating dentists agree to a discounted fee schedule for services rendered to patients.

27. Amount of dental expenses a covered person must pay before the dental plan benefits begin.

28. 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.

29. 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.

30. Fee a dentist most frequently charges for a given dental service.

31. Authorization by the enrollee/patient for the dental benefits carrier to make payment for covered services directly to the treating dentist

32. Consolidated omnibus budget reconciliation act which allows a person to temporarily maintain insurance coverage even if he/she loses job.

33. Fee for service/services determined to be representative of the fees charged by dentist in a specific region or geographical area.

34. Period during which employees or group members can enroll in health care programs.

35. Fee for service dental benefits program in which payment of benefits is based on reasonable and customary fee criteria.

36. Maximum dollar amount the benefit carrier allows for each dental procedure

37. Dental services that's payable under the terms of the benefit program.

38. 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.

39. Unique identification number. NPI part of HIPAA

40. Dental benefits program in Which benefits are provided only if care is rendered by institutional and professional providers with whom the plan contracts.

41. Individuals - such as spouse and children - who are legally and contractually eligible for benefits under a subscriber's dental benefits contract.

42. Dental services that are not covered under a dental benefits program--excluded from plan

43. Restrictions stated in a dental benefits contract that limit the scope of coverage.

44. Reporting a more complex or more expensive procedure that was actually performed. Fraudulent.

45. Detailed statement of a processed claim showing the patient - provider - procedure codes - date of service - the carrier's payment - and the patient's copayment.

46. Benefit carrier that has initial responsibility for benefit payment when a patient is covered by tow or more carriers.

47. Federal assistance program; provides payment for medical care from the federal government.

48. 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.

49. Person or company who manages or directs a dental benefits program on behalf of the program's sponsor

50. Dentist who does not have a contract agreement with benefits carrier.