Adjacent: Together, side by side.
Allowable Charge: The maximum dollar amount on which benefit payment is based for each dental procedure.
Alternate Benefit: A provision in a dental plan contract that allows the third-party payer to determine the benefit based on an alternative procedure that is generally less expensive than the one provided or proposed.
Anterior Teeth: Permanent teeth 6-11 upper, 22-27 lower; Primary teeth C-H upper, M-R lower. Please consult with your dentist if you have any questions regarding tooth location.
Bi-lateral: Affecting both sides of the mouth.
Birthday Rule: When a dependent child’s parents both have dental coverage, this rule states that the "primary" program (the one which pays first) is the one covering the parent whose month and day of birth falls first in the calendar year. The birthday rule is the most common rule for determining primary vs. secondary coverage, but it may be superseded by a court order such as a divorce agreement.
Cafeteria Plan: A benefit program in which you are given a certain amount (in dollars or points) to be used toward your choice of benefits. You then select (cafeteria style) which benefits you would like from a list provided by your employer. Also known as 'flexible benefits.'
Capitation: A dental benefit program in which a network dentist agrees to provide all or most covered dental services to those who enroll with his/her office. The carrier pays the network dentist per capita (for each enrolled patient) rather than per service. See 'health maintenance organization.'
Completion Date: The completion date is the date of insertion for removable prosthetic appliances. The completion date for fixed partial dentures and crowns, onlays, and inlays is the cementation date regardless of the type of cement utilized.
Component Part: Procedure is considered part of final treatment and patient is not responsible for additional charges.
Consecutive Months: Months occurring consecutively (not the same as a calendar year). Example: If your policy covers two cleanings in a 12-consecutive-month period, the first cleaning occurs July 5, 2024 and the second January 5, 2025 - patient is not eligible for this service again until July 5, 2025.
Contract Year: The 12-month period over which a group’s deductibles, maximums and other provisions apply. This may or may not be the same as a calendar year. Also known as the benefit year.
COB: Coordination of Benefits. When you are covered by more than one benefit plan, the two benefits are coordinated so that no more than 100 percent of the total covered expenses is paid. See "non-duplication of benefits" and 'birthday rule.'
Copayment: Your share of the cost of a given service. It may be a percentage of the dentist’s approved fee or a fixed dollar amount.
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Deciduous Teeth: Baby/primary teeth; A-T.
Deductible: The amount you pay for treatment before certain benefits are paid. In most programs, deductibles must be met each year.
DeltaUSA: The umbrella term for all national programs offered by Delta Dental. They include: Delta PremierUSA, DeltaPreferred Option USA and DeltaCare USA.
Denied: If the fee for a procedure or service is denied and chargeable to the patient, the procedure or service is not a benefit of the patient’s plan. The approved amount is not payable by Delta Dental, but is collectable from the patient.
Dual Choice: An option that allows you to select from two or more types of dental programs. Also called "dual option."
Dual Coverage: When you have coverage under more than one benefit program. The primary and secondary carriers coordinate the two programs, so that the primary carrier pays its portion first and the secondary carrier usually pays the remainder. See "Non-duplication of benefits" and "birthday rule."
Enrollee: This word applies to the person who is covered under a Delta Dental program. An enrollee may also be referred to as a subscriber or patient.
E.O.B: Explanation of Benefits. The statement you are mailed detailing how your claim payment was calculated. It is sometimes called a Notice of Payment.
Extracoronal: To place an appliance on top or outside of tooth (orthodontic brackets).
Extraoral: Outside of the mouth.
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Fee-for-Service: A program design in which the dentist is paid for each service, rather than a fixed amount per patient, which is how many HMOs work. The fee-for-service method is the traditional way of delivering dental benefits.
Fee Listing/Filed Fees: Every Delta Dental dentist submits a list of fees to Delta Dental. They are used to calculate Delta Dental’s payment and the patient’s payment.
Fixed Prosthesis: An appliance, which is cemented; bridges.
I & D: Incision and Drainage.
Impression Date: Date on which a dentist takes an impression for a crown or complete denture/partial denture.
Incentive Program: A program that promotes prevention by increasing coverage from one benefit period to the next as long as you visit the dentist regularly. For instance, cleanings might be covered at 70 percent during the first year, 80 percent during the second year and up to 100 percent as long as the program is used at least once a year.
Initial: Beginning of a process; first denture or partial denture.
Inlay: A solid filling made to the precise shape of a cavity of a tooth and cemented into it.
Interim Partial/Denture: Temporary partial or denture designed to replace anterior teeth during the healing process or as an anterior space maintainer for children.
Intracoronal: To place the appliance into the tooth once a prep has been made; cemented into the prepared area.
Intraoral: Within the mouth.
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Mandibular (mandible): The lower jaw.
Maxillary (maxilla): The upper jaw.
Maximum: A dollar limit that is applied to benefit payments. Some programs have no maximum. Some maximums apply to the lifetime of the benefit program; others apply to a particular period of time (calendar year, benefit year, etc.) or particular services (such as separate maximum for orthodontic benefits).
Maximum Allowable: Term for the maximum fee charged and collected for a given service by a particular dentist.
N.A.B: Not a Benefit, patient is responsible.
Network: Dentists who have contractually agreed to treat Delta Dental subscribers and accept payment according to those administrative guidelines.
N.N.A.: Need Not Apparent.
Non-Duplication of Benefits: If you are covered by two programs (dual coverage), non-duplication of benefits is a term used to describe one of the ways the secondary carrier may calculate its portion of the payment. The secondary carrier calculates what it would have paid if it were the primary plan and subtracts what the other plan paid. For example, if the primary carrier paid 80 percent, and the secondary carrier normally covers 80 percent as well, the secondary carrier would not make any additional payment. If the primary carrier paid 50 percent, however, the secondary carrier would pay up to 30 percent.
O.H.I.: Oral Hygiene Instructions.
Onlay: A crown like structure, which is placed on the tooth structure not to cover the entire, tooth and cemented on the tooth.
Out-of-Pocket Costs: Any amount you are responsible for paying, such as copayments, deductibles and costs above your annual maximum.
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Payment Protection: A feature of most programs that protects you from unexpected expenses. For example, in a DeltaPremier fee-for-service program that pays an 80 percent benefit on covered services, you are assured that your copayment will not be more than the remaining 20 percent, as long as you have gone to a participating Delta Dental dentist.
Permanent Teeth: Adult teeth, 1-32. Please consult with your dentist if you have any questions regarding tooth location.
Policy Number: Your policy number is either the employee’s social security number (SSN) or member ID number.
Posterior Teeth: Permanent teeth 1-5, 12-21 and 28-32, teeth which are behind the canine teeth, molars and bicuspids (premolars); Primary teeth A-B, I-L and S-T. Please consult with your dentist if you have any questions regarding tooth location.
PPO: Preferred Provider Organization. A program that allows you to utilize any dentist, but provides financial incentives to choose a dentist who participates in the PPO network. DeltaPreferred Option is a PPO program.
Predetermination: Gives an estimate of how much of a proposed treatment plan will be covered under your dental program. A predetermination lets you figure your costs before you receive major treatment. Any enrollee can ask the dental office to submit a predetermination request.
Pre-existing condition: An example of a pre-existing condition is a tooth that was extracted prior to an enrollee receiving coverage. Many dental carriers routinely exclude coverage for pre-existing conditions; most Delta Dental programs cover them.
Prep Date: Date a tooth is prepared for a permanent restoration (e.g., inlay, onlay, veneer, crown).
Primary: Baby teeth, A-T: deciduous teeth. Please consult with your dentist if you have any questions regarding tooth location.
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Quadrant: One of the four equal sections into which the dental arches can be divided; begins at the midline of the arch and extends distally to the last tooth.
Rebase: To refit a denture by replacing the base material (acrylic) without altering the occlusal characteristics, reuse of false teeth. Done by lab only.
Reline: Replacing or resurfacing the lining of a denture. Applying more acrylic to inside of denture or partial. Can be done chair-side or lab.
Removable Prosthesis: Upper or lower partial or complete denture.
Replacement: Replacing of the first denture/partial denture or crown/filling.
Seat Date: Date in which the crown/bridge is cemented onto the tooth.
Sextant: One of the six relatively equal sections into which a dental arch can be divided, for example: tooth number 1-5; 6-11; 12-16; 17-21; 22-27; 28-32. Sometimes used for recording periodontal charting. Please consult with your dentist if you have any questions regarding tooth location.
Surfaces: M-Mesial, D-Distal, O-Occlusal, L-Lingual, B-Buccal, for anterior teeth I-Incisal, F-Facial.
T.M.J.: Temporomandibular Joint.
Unilateral: Affecting or occurring only on one side.
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