Balance Billing — The practice of billing a patient for the difference between what the dentist charges and the agreed-upon charge established by Delta Dental. In-network dentists cannot balance bill patients.
Benefit Period — A specified period to incur covered benefits in order for them to be eligible for payment. This is also the specified period of time that your deductible (if any) and maximum (if any) is calculated. Also see "Benefit Year."
Benefit Year — The 12-month period your dental plan covers, which is not always a calendar year. For example, a benefit year could run June-May instead of January-December. This is also known as a plan year. Also see "Benefit Period."
Benefit Levels — Dental treatments are grouped into levels. The percentage covered by your dental plan often varies by benefit level. Most plans include the following benefit levels:
Certificate of Coverage — A booklet you receive from Delta Dental that explains your benefits coverage in detail. (Also known as "member handbook" or "evidence of coverage.") Log into the subscriber portal to access yours.
Claim/Claim Form — Information the dentist submits to the dental plan to get paid for services performed on a patient.
Coinsurance — A fixed percentage of a dental treatment cost that you share with your dental plan. For example, Delta Dental may pay 80% of a given service, while you are responsible for the other 20%. Coinsurance kicks in after you meet your deductible.
Copayment — A set dollar amount you are required to pay your dentist for a service. An enrollee usually has a copayment or coinsurance, but not both. (Also known as "copay.")
Covered Service — A dental treatment or procedure paid for, either partially or fully, by your dental benefits.
Coodination of Benefits — Guidelines that determine how each dental plan pays when you are covered by more than one dental plan.
Credentialing — A process to ensure a dentist is properly trained to treat patients before being able to be a part of Delta Dental's networks.
Deductible — A set dollar amount you are responsible for before your dental plan begins to pay for covered services.
Dental Necessity — Benefits covered by the dental plan that the dental carrier determines are necessary for the diagnosis and treatment of your condition.
Dentist — See "Dental Professionals."
Dependents — Anyone covered under a dental plan other than the primary subscriber, such as a spouse or children.
Dual Coverage — Coverage under two separate dental plans — for instance, if a child is covered by dental plans from both parents. Also see "Coordination of Benefits."
Effective Date — The date you can start using your dental benefits plan.
Enrollee — A person covered under a dental plan. Also See "Dependents."
Evidence of Coverage (EOC) — See "Certificate of Coverage."
Exclusions — Dental services or procedures not covered by your dental plan.
Explanation of Benefits (EOB) — A document Delta Dental provides after a procedure that contains a summary of the treatments you received, including the treatment cost, the portion covered by your dental plan and the portion you may owe. An EOB is not a bill.
Fee Schedule — A list of charges for specific dental treatments agreed to by both the dental plan and the dentist.
Group — A company or organization that provides dental benefits to its employees or members. The group works with Delta Dental to select the plan type, benefit levels, maximums and member eligibility.
HIPAA — Stands for "Health Insurance Portability and Accountability Act of 1996," a federal law intended to improve access to health coverage, limit fraud and abuse, protect personal health information (PHI) and control administrative costs.
Lifetime Maximum — The maximum amount a plan will pay over the course of a lifetime. The lifetime maximum may apply to an individual or a family and usually applies to specific treatments, such as orthodontia.
Limitations — Conditions, such as age and period of time covered, that restrict a dental plan's coverage for certain services.
Maximum Benefit — See "Annual Maximum."
Maximum Plan Allowance (MPA) — The amount set by Delta Dental that a Delta Dental Premier® dentist has agreed to charge for a service.
Member — See "enrollee."
Member Handbook — See "Certificate of Coverage."
National Provider Identifier (NPI) — A unique identification number used to identify a health care professional as an alternative to their dental license number.
Network — Dentists who have signed up with Delta Dental to provide dental care at agreed-upon fees.
Non-Participating Dentist — See "Out-of-Network" Dentist.
Open Enrollment — The period of time during which employees or qualified individuals can enroll in or make changes to benefit plans.
Optional Services — Procedures not covered under the terms of a dental benefits contract. Delta Dental will review claims for optional services to determine what amount, if any, will be paid for the service.
Out-of-Network Dentist — A dentist who has not signed up to participate with Delta Dental. Also known as "non-participating dentist."
Participating Dentist — See "In-Network Dentist."
Plan Year — See "Benefit Year."
Pre-Determination — See "Pre-Treatment Estimate."
Pre-Established Fee — The amount set by Delta Dental that an in-network dentist has agreed to charge for a service.
Premium — The amount the enrollee pays for dental benefits, usually paid monthly, quarterly or annually.
Pre-Treatment Estimate — A treatment plan usually submitted by a dentist for Delta Dental to review and provide an estimate of benefits before treatment starts. Pre-treatment estimates can help you budget for dental procedures. They can also help you and your dentist decide how to proceed with a treatment. Sometimes referred to as pre-authorization or pre-determination.
Processing Policies — Clinical guidelines to validate that a dental treatment or procedure meets the criteria set by your dental plan. Processing policies may change occasionally. If a processing policy is applied to a billed service, it will be explained on the Explanation of Benefits (EOB).
Protected Health Information (PHI) — Personal information about a patient, such as a Social Security number and medical history, which is required to be stored securely by health care entities such as a doctor, dentist, health clinic or health insurer.
Provider — See "Dental Professionals."
Qualifying Event — A change in your family, employment or group coverage status that would affect your benefits under your dental plan, such as marriage, divorce or the birth of a child. For a list of qualifying events, log in and download your member handbook.
Subscriber — A person who has signed up for dental coverage from Delta Dental. If family coverage is offered, additional people covered will be listed as the subscriber's spouse or dependents.
Termination Date — The date your dental benefits coverage ends or you are no longer eligible for benefits.
Waiting Period — A period of time before you are eligible to receive benefits for all or certain dental treatments.
DHMO (Dental Health Maintenance Organization) — Also referred to as pre-paid plans, DHMOs require you to choose one dentist or dental facility for all of your oral health needs. These plans don't have deductibles or maximums. An enrollee pays a fixed dollar amount (copayment) to the dentist at visits. Delta Dental's DHMO plan is called DeltaCare® USA.
Discount Card/Plan — An option for individuals and families that do not have dental benefits. Enrollees have access to dentists who have agreed to charge discounted fees for certain services. Patients pay the agreed-upon fee directly to the dentist. A discount card/plan is not insurance.
Individual and/or Family Plan — Dental plans that individuals and their families can purchase directly from Delta Dental rather than through an employer. Find out more about our individual plans.
Managed Fee-for-Service — A type of dental plan where participating dentists agree to fee schedules that can provide discounts for dental care. Delta Dental's managed fee-for-service option is called Delta Dental Premier®.
PPO (Preferred Provider Organization) — A dental plan in which participating dentists agree to fee schedules that provide deeper discounts and lower out-of-pocket expenses. Delta Dental's PPO options are called Delta Dental PPOTM and Delta Dental PPO plus PremierTM.
Voluntary — A dental benefits plan offered through an employer where employee participation is optional. Employers usually don't help cover the cost of the plan but still allow employees to enjoy pre-tax savings on premiums through payroll deduction. If your employer offers a Delta Dental voluntary plan, here are 3 reasons to enroll.
Endodontist — A dental specialist who treats disease and injuries of the tooth pulp. A patient who needs a root canal may be treated by an endodontist.
General Dentist — A primary dental care provider with a broad range of general oral health expertise. General dentists perform preventive care as well as many restorative procedures such as fillings, crowns, implants and more.
Hygienist — A licensed dental professional who assists or performs procedures such as screenings, X-rays and cleanings. The range of services hygienists can perform varies from state to state.
Oral Maxillofacial Radiologist — A dental specialist who performs and reads diagnostic imagery (such as X-rays, CT scans and ultrasounds) used to examine bones in the skull and face, as well as dental structures
Oral Pathologist — A dental specialist trained to diagnose dental diseases
Oral Surgeon — A dental specialist trained to perform dental surgeries such as wisdom teeth removal, dental implants and more
Orthodontist — A dental specialist who treats the misalignment of the teeth and their surrounding structures, using appliances such as braces and retainers.
Pediatric Dentist — A dental specialist who treats children; formerly known as a pedodontist
Periodontist — A dental specialist who treats diseases of the supporting and surrounding tissues of the teeth. Patients with periodontal (gum) disease are treated by a periodontist.
Prosthodontist — A dental specialist who restores natural teeth and replaces missing teeth with artificial substitutes, like implants or dentures
Specialist — A dentist who concentrates on one discipline, such as pediatric dentistry, orthodontia or prosthodontics.