Glossary: 36 terms
Dental insurance verification glossary
The words on a benefit breakdown sheet, defined the way a coordinator uses them. Every entry says which row of the worksheet it lands on, and the ones Ardent answers a question about link to that answer. Definitions describe how plans commonly work; a patient’s plan can differ, and the payer’s statement is what goes on the sheet.
A to Z
Dental insurance terms, as they appear on a breakdown sheet
Each term below is defined the way a front desk uses it, with the row of the worksheet it lands on. The fictional examples come from the sample sheet on the verification page.
A
Alternate benefit clause (downgrade) #
A plan provision under which the payer pays for the least expensive treatment that would adequately restore the tooth, and the patient pays the difference for the treatment actually done. The common cases are a posterior composite filling paid as an amalgam and a crown paid at a lower-cost material.
On the sheet: The general worksheet asks POST COMP: COVERED or REDUCED, and on the crown row, IF SO WHAT CODE TO ALTERNATE.
Annual maximum #
The most a plan will pay for a patient’s dental care in one benefit year. Once it is reached, the patient pays the full contracted fee for further treatment until the next benefit year begins. Some plans exclude diagnostic and preventive care from the maximum.
On the sheet: MAXIMUM $ on the general worksheet, with REM MAX $ for what is left and DIAG/PREV COME OUT OF MAX: YES/NO.
B
Benefit year: calendar or contract #
The twelve months over which a plan’s maximum and deductible apply. A calendar-year plan resets on January 1; a contract-year plan resets on the anniversary of the group’s effective date, so remaining benefits have to be read against the right date.
On the sheet: The CAL/CONT choice beside MAXIMUM $.
Benefits breakdown #
The document a practice fills in for an insured patient before the visit, also called a breakdown of benefits, benefit breakdown form or insurance verification worksheet. It records the plan’s maximum and remaining benefit, deductible, coverage percentages by category, frequency and age limits, waiting periods, missing tooth and downgrade clauses and pre-authorization rules, so the office can estimate the patient’s share.
On the sheet: The whole sheet. Ardent fills the practice’s own breakdown form rather than replacing it.
Bitewings, FMX and panoramic X-rays #
Bitewing X-rays (BWX, D0272 to D0274) show the crowns of the back teeth and are typically covered once or twice a year. A full mouth series (FMX, D0210) and a panoramic film (pano, D0330) are covered less often, commonly once in three to five years, and many plans count them against one shared frequency.
On the sheet: BWX, FMX and PANO frequencies, with (SHARED / SEP.) beside the FMX and pano rows.
Business Associate Agreement (BAA) #
The HIPAA contract between a covered entity, such as a dental practice, and a vendor that handles protected health information on its behalf. It sets out how the vendor may use, protect and return or destroy that information.
C
CDT codes #
The Current Dental Terminology procedure codes maintained by the American Dental Association. Each is a D followed by four digits: D0120 for a periodic exam, D1110 for an adult prophylaxis, D2740 for a porcelain crown, D4341 for scaling and root planing, D8090 for comprehensive orthodontic treatment. Payers state coverage, frequency and age limits by code.
On the sheet: Most rows on a breakdown sheet name the code they ask about.
Claims address and payer ID #
Where the payer receives claims: a mailing address for paper claims and a payer ID for electronic ones. Both are read from the payer’s portal or the patient’s card rather than assumed, since large carriers route claims to different addresses by plan.
On the sheet: CLAIMS ADDRESS and PHONE# on the general worksheet.
Coordination of benefits (COB) #
The rules for paying a claim when a patient has more than one dental plan. The primary plan pays first, the secondary plan may pay some or all of what remains, and the payers decide which is primary; for a dependent child the birthday rule, under which the parent whose birthday falls earlier in the calendar year holds the primary plan, is the usual method.
On the sheet: The PRIMARY / SECONDARY / THIRD choice in the sheet’s title, one sheet per plan.
Coverage percentage (coinsurance) #
The share of the contracted fee the plan pays for a category of care, with the patient paying the rest. A common structure is 100% for diagnostic and preventive care, 80% for basic restorative work and 50% for major work such as crowns, but the split and which procedures fall in which category vary by plan.
On the sheet: DIAG/PREV %, BASIC %, PERIO %, MAJOR %, OS %, ENDO % on the general worksheet.
D
Deductible #
The amount a patient pays each benefit year before the plan starts paying its percentage, stated per person and per family. Many plans waive the deductible for diagnostic and preventive care.
On the sheet: DED $ with the individual and family amounts (50/150 in the fictional example), MET: YES/NO and WAIVED: YES/NO.
Dependent age limit and student status #
The age at which a child stops being covered under a parent’s plan, commonly 26 under federal rules for medical plans and mirrored by many dental plans, sometimes with an older limit for full-time students. Pediatric and orthodontic offices verify it on every dependent.
On the sheet: CHILDREN COVERED UPTO AGE and STUDENTS on the general worksheet; DEP COVERED TO AGE on the pediatric breakdown.
E
EDI 270/271 #
The HIPAA-standard electronic eligibility inquiry (270) and response (271) a practice or its clearinghouse sends to a payer. It confirms whether coverage is active on the date of service and sometimes returns a few benefit lines, but it rarely answers a full breakdown.
Effective date and termination date #
The day a patient’s coverage began and, where the payer states one, the day it ends. A plan the payer shows as terminated before the appointment is the most common reason a verification cannot be completed.
On the sheet: EFF. DATE on the general worksheet. Ardent flags a terminated plan in the 7:00 AM email.
Eligibility #
Whether a patient is covered by the plan on the date of service. It is a yes-or-no question answered by a 270/271 transaction or a portal lookup, and it is only the first part of verification.
Estimated patient portion (copay) #
What the patient is expected to pay for a visit after the plan’s share is applied: the deductible if unmet, the patient’s percentage of each contracted fee, and anything not covered. It is an estimate until the claim is adjudicated.
On CareStack, Ardent adds a coverage line with an estimated copay
F
Fee schedule #
The list of contracted fees an in-network dentist has agreed to accept from a payer, by procedure code. The plan’s percentage is applied to the contracted fee, not to the office’s full fee, and the difference is written off.
On the sheet: FEE SCH on the general worksheet (Delta PPO in the fictional example).
Frequency limitation #
How often a plan covers a procedure: twice per calendar year for a prophylaxis, once every 36 months for a full mouth series, once every 60 months per tooth for a crown. Treatment inside the limit is paid by the patient, so frequencies and the dates of the last services are verified together.
On the sheet: FREQ beside most rows, written in the office’s shorthand: 2xC/Y, 1x36m, 1x60m/tooth.
G
Group number and employer #
The identifier for the employer’s plan with the payer, and the employer’s name. Together with the member ID they locate the patient’s exact plan, since one employer may offer several.
On the sheet: EMPLOYER and GROUP# on the general worksheet.
I
In-network and out-of-network #
An in-network dentist has a contract with the payer and accepts its fee schedule; an out-of-network dentist has not, so the plan may pay a lower percentage or pay against a usual-and-customary fee, and the patient pays the balance. PPO plans allow both; DHMO plans cover only assigned in-network dentists.
Insurance verification #
Confirming, before an appointment, that a patient’s plan is active and documenting what it covers: maximum and remaining benefits, deductible, coverage percentages, frequency limits, waiting periods, missing tooth and downgrade clauses and pre-authorization rules. Offices do it by payer portal, phone, fax or a 270/271 transaction, and record the result on a breakdown sheet.
IVR and benefits fax (faxback) #
A payer’s automated phone line (interactive voice response) that can fax a benefits summary to the practice on request. For payers that answer this way, the fax is the payer’s own document and the most reliable source for a breakdown.
L
Lifetime maximum (orthodontic) #
A cap on what a plan pays for orthodontic treatment over the patient’s lifetime rather than per year, commonly $1,000 to $2,500. Orthodontic benefits are usually paid out over the course of treatment, automatically, monthly or quarterly.
On the sheet: ORTHO MAX: $, REM: $ and INS WILL PAY: AUTO / MONTHLY / QUARTERLY on the general worksheet; ORTHO LIFETIME MAX $ on the orthodontic worksheet.
M
Member ID and subscriber #
The subscriber is the person who holds the plan, usually through an employer; the member ID is the identifier the payer assigns, printed on the card. Dependents are covered under the subscriber, and a verification starts by matching the patient to the subscriber’s record.
On the sheet: SUBSCRIBER, SSN# or ID# and SUB. DOB on the general worksheet.
Missing tooth clause #
A plan provision that excludes coverage for replacing a tooth lost before the patient’s coverage began. It matters before treatment-planning a bridge, an implant or a partial denture.
On the sheet: PRIOR EXT COVERED? on the general worksheet, answered YES or NO only when the payer states it.
P
Payer (carrier) #
The insurance company or plan administrator that pays claims. Some names cover many payers: Delta Dental is 39 independent member companies, each with its own portal and its own rules, so a verification is done with the member company that holds the patient’s plan.
On the sheet: INSURANCE CARRIER on the general worksheet.
Payer portal (provider portal) #
The payer’s website for dental offices, where a practice signs in with its own credentials to look up a patient’s eligibility, benefits, claim status and often a benefits summary document. Portals answer most of a breakdown; what they leave blank is asked by phone.
Plan types: PPO, DHMO, Premier, indemnity #
A PPO plan pays for care from any dentist but pays more, against a contracted fee schedule, in network. A DHMO (dental HMO) covers only care from the dentist the patient is assigned to, usually with fixed copays. Delta Dental Premier is Delta Dental’s largest fee-for-service network with its own fee schedule. An indemnity plan pays a percentage of a usual-and-customary fee with no network.
On the sheet: PLAN TYPE on the general worksheet, circled from what the payer states.
Practice management system (PMS) #
The software a dental office runs on: the schedule, patient records, insurance on file, ledger and chart documents. Dentrix, Eaglesoft, Open Dental, CareStack and Curve Dental are examples. A verification starts from the appointment and insurance the PMS holds and ends with the completed sheet filed back into it.
Pre-authorization and predetermination #
A predetermination (pre-treatment estimate) is a claim sent before treatment so the payer states what it will pay; a pre-authorization is a payer’s requirement that it approve certain procedures in advance. Many plans recommend or require one above a dollar threshold or for major work.
On the sheet: P PRE-AUTH RECOM or REQ and AMOUNT $ on the general worksheet; PRE-D REC >$300 in the fictional example.
Prophylaxis and periodontal maintenance #
A prophylaxis (prophy, D1110 for adults and D1120 for children) is a routine cleaning; periodontal maintenance (D4910) is the ongoing care after scaling and root planing (D4341 and D4342, billed per quadrant). Plans limit how many quadrants of scaling they pay per day and sometimes require an interval between a prophy and perio maintenance, or count them against one frequency.
On the sheet: PROPHY, PERIO, HOW MANY QUADS PER DOS?, WAITING PERIOD AFTER PROPHY/PERIO and D4910 SHARED W/PRO? on the general worksheet.
S
Sealants and fluoride age limits #
Sealants (D1351) are usually covered on permanent molars only, once per tooth in a span of years and up to an age limit; topical fluoride (D1206, D1208) is covered a set number of times a year up to an age limit. Pediatric breakdowns verify which teeth and which ages.
On the sheet: FLUORIDE % AGE LIMIT and SEALANTS D1351 FREQ per tooth AGE LIMIT on the general worksheet; the sealant teeth row on the pediatric breakdown.
T
Timely filing #
The deadline after the date of service by which a payer must receive a claim, commonly 90 days to a year. A claim filed late is denied regardless of the benefit.
On the sheet: TIMELY FILING on the orthodontic worksheet.
W
Waiting period #
Time after a plan’s effective date before certain categories of care are covered, commonly six to twelve months for basic or major work and longer for orthodontics. Preventive care usually has none.
On the sheet: WAITING PERIOD on the general worksheet; WAITING PERIOD 12 months on the orthodontic worksheet in the fictional example.
Work in progress (orthodontic) and banding date #
Whether a plan pays for orthodontic treatment that began under a previous plan, and the banding date, the day appliances were placed, which payers use to pro-rate the benefit and to decide whether treatment started before coverage.
On the sheet: BANDING DATE REQUIRED and WORK IN PROGRESS COVERED on the orthodontic worksheet.
Worksheet notation: 2xC/Y, 1x36m, NL, NC #
The shorthand coordinators write on a breakdown sheet. 2xC/Y is twice per calendar year; 1x36m is once every 36 months; 1x60m/tooth is once every 60 months per tooth; NL is no limit; NC is not covered. Ardent writes values in whatever shorthand the office already uses, prints NC only for a stated exclusion, and leaves a blank empty when nobody stated a value.
On the sheet: Every FREQ, %, and AGE LIMIT blank.