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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. Organization that bears the financial risk for the cost of defined categories or services for a defined group of policy holders or beneficiaries.
Customary fee
Usual fee
Insurer
Overcoding
2. Dental benefits program in Which benefits are provided only if care is rendered by institutional and professional providers with whom the plan contracts.
Exclusions
Direct Billing
Customary fee
25. Exclusive Provider Organization (EPO) plan
3. Date an individual and/or dependents become eligible for benefits under a dental benefits contract.
Open enrollment
Limitations
Waiting period
Effective Date
4. Treatment plan submitted to the benefit carrier for review and estimate of payment before services are rendered.
Predetermination
Usual fee
Reasonable and customary (R&C) plan
Covered services
5. Unique identification number. NPI part of HIPAA
Claim Form
National Provider Identifier (NPI)
Waiting period
Primary Carrier
6. 12 month period of the dental contract (not always a calendar year)
Expiration Date
Balance Billing
Customary fee
Benefit year
7. Dental services that are not covered under a dental benefits program--excluded from plan
Fee for service plan
Direct Billing
Open enrollment
Exclusions
8. Dental benefits program in which participating dentists agree to a discounted fee schedule for services rendered to patients.
Predetermination
Exclusions
Preferred provider organization (PPO)
Capitation
9. Dental benefits program in which a dentists are paid for each covered service rendered to an eligible enrollee.
Fee for service plan
Open Panel System
National Provider Identifier (NPI)
Exclusions
10. 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
27. Explanation of benefits EOB
Closed Panel System
Capitation
Allowed amount
11. Reporting a more complex or more expensive procedure that was actually performed. Fraudulent.
Overcoding
Maximum allowable benefit (MAB)
Waiting period
Closed Panel System
12. Benefit carrier that has initial responsibility for benefit payment when a patient is covered by tow or more carriers.
Primary Carrier
Nonparticipating dentist
Direct Reimbursement
16. Current Dental Terminology (CDT)
13. Fee for service dental benefits program in which payment of benefits is based on reasonable and customary fee criteria.
Assignment of Benefits
Benefit administrator
Reasonable and customary (R&C) plan
Nonparticipating dentist
14. Services covered by a benefit plan. Payment for these services may be subject to plan maximums - limitations - and deductibles
Approved Services
Overcoding
Expiration Date
Insurer
15. Federal Law intended to improve access to health insurance - limit fraud and abused - and control administrative costs.
Claim Form
Effective Date
Predetermination
HIPAA
16. Person who files a claim for reimbursement of covered costs (the dentist & practice)
27. Explanation of benefits EOB
Claimant
Effective Date
Fee Schedule
17. Health care coverage system which employers offer a list of options for health care benefits.
Balance Billing
Medicaid
Cafeteria Plan
Limitations
18. Restrictions stated in a dental benefits contract that limit the scope of coverage.
Limitations
16. Current Dental Terminology (CDT)
Reimbursement
Medicaid
19. Person who is eligible for benefits under a dental benefits contract; AKA member - insured individual - participant - beneficiary.
Enrollee
Closed Panel System
Reasonable and customary (R&C) plan
Primary Carrier
20. Amount or percentage of the dentist's fee that the patient is obligated to pay.
Reasonable and customary (R&C) plan
Benefit administrator
Direct Billing
Copayment
21. Individuals - such as spouse and children - who are legally and contractually eligible for benefits under a subscriber's dental benefits contract.
Effective Date
Benefit year
Maximum allowable benefit (MAB)
Dependents
22. Amount of dental expenses a covered person must pay before the dental plan benefits begin.
Predetermination
Preferred provider organization (PPO)
Deductible
Limitations
23. 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.
Cafeteria Plan
Birthday Rule
Open Panel System
Claimant
24. 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.
Birthday Rule
Allowed amount
Open Panel System
Reimbursement
25. Paper form used to request payment or predetermination for patients covered by a dental benefits program.
27. Explanation of benefits EOB
Table of allowance plan
Deductible
Claim Form
26. Dentist who does not have a contract agreement with benefits carrier.
Preexisting condition
Nonparticipating dentist
Enrollee
Direct Reimbursement
27. Detailed statement of a processed claim showing the patient - provider - procedure codes - date of service - the carrier's payment - and the patient's copayment.
Premium
27. Explanation of benefits EOB
Overcoding
Direct Billing
28. Person or company who manages or directs a dental benefits program on behalf of the program's sponsor
Allowed amount
Dependents
Benefit administrator
Exclusions
29. Dental services that's payable under the terms of the benefit program.
Open Panel System
Cafeteria Plan
25. Exclusive Provider Organization (EPO) plan
Covered services
30. 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.
Table of allowance plan
Balance Billing
Claim Form
Reimbursement
31. List of charges established by or agreed to by a dentist for specific dental services listed by ADA procedure codes.
Fee Schedule
Open Panel System
Claim Form
Fee for service plan
32. Period during which employees or group members can enroll in health care programs.
Effective Date
Open enrollment
Waiting period
Medicaid
33. Maximum dollar amount the benefit carrier allows for each dental procedure
Covered services
Open enrollment
Benefit administrator
Allowed amount
34. 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)
Customary fee
Direct Reimbursement
Covered services
35. 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.
Enrollee
Open Panel System
Maximum allowable benefit (MAB)
Assignment of Benefits
36. Oral health condition that existed before a person enrolled in a dental program.
Primary Carrier
Deductible
Allowed amount
Preexisting condition
37. Requiring payment in full from the patient/responsible party for all services rendered.
Direct Billing
Fee for service plan
Medicaid
National Provider Identifier (NPI)
38. 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.
Overcoding
Cafeteria Plan
Usual fee
Open Panel System
39. Authorization by the enrollee/patient for the dental benefits carrier to make payment for covered services directly to the treating dentist
Assignment of Benefits
Covered services
Benefit administrator
Limitations
40. Consolidated omnibus budget reconciliation act which allows a person to temporarily maintain insurance coverage even if he/she loses job.
Open Panel System
COBRA
Insurer
Nonparticipating dentist
41. Employee or participant who is certified by the company who receives benefit coverage.
Capitation
Exclusions
Subscriber
16. Current Dental Terminology (CDT)
42. Amount charged by a dental benefits carrier for coverage.
Benefit year
Premium
Benefit administrator
Maximum allowable benefit (MAB)
43. Federal assistance program; provides payment for medical care from the federal government.
Table of allowance plan
16. Current Dental Terminology (CDT)
Medicaid
Covered services
44. 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.
Assignment of Benefits
Predetermination
Table of allowance plan
Cafeteria Plan
45. Employer's or organization's self funded program for reimbursing covered individuals based on a percentage of the amount spent for dental care.
Limitations
Nonparticipating dentist
Benefit year
Direct Reimbursement
46. Date on which the dental benefits or contract expires or date an individual ceases to be eligible for benefits.
Expiration Date
Reimbursement
Overcoding
Fee Schedule
47. Fee a dentist most frequently charges for a given dental service.
Customary fee
COBRA
Fee for service plan
Usual fee
48. Period between employment or enrollment in a dental program and the date the enrollee became eligible for benefits.
National Provider Identifier (NPI)
Deductible
Cafeteria Plan
Waiting period
49. Fee for service/services determined to be representative of the fees charged by dentist in a specific region or geographical area.
Subscriber
Birthday Rule
Exclusions
Customary fee
50. 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.
Usual fee
Subscriber
Preexisting condition
Closed Panel System