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American Association of Dental Consultants
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Dental Benefit Terminology Use this section as a Dictionary; by selecting a letter in the index at the top to view the corresponding terms. When you are finished viewing a section, click the "TOP OF PAGE" link and you will return to the Glossary index.
A Administrative Costs: Overhead expenses incurred in the operation of a dental benefit program, exclusive of costs of dental services provided. Administrative Services Only (ASO): An arrangement under which a third party, for a fee, processes claims and handles paperwork for a self-funded group. This frequently includes all insurance company services (actuarial services, underwriting, benefit description, etc.) except assumption of risk. Adverse Selection: A statistical condition within a group when there is a greater demand for dental services and/or more services necessary than the average expected for that group. 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. Alternative Benefit Plan: A plan, other than a traditional (fee-for-service, freedom-of-choice) indemnity or service corporation plan, for reimbursing a participating dentist for providing treatment to an enrolled patient population. Alternative Delivery System: An arrangement for the provision of dental services in other than the traditional way (e.g., licensed dentist providing treatment in a fee-for-service dental office). Any Willing Provider: Legislation that requires managed care organizations (MCOs), such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs) to contract with any providers, from physicians and hospitals to pharmacists and chiropractors, who are willing to meet the terms of the contract. Assignment of Benefits: A procedure whereby a beneficiary/patient authorizes the administrator of the program to forward payment for a covered procedure directly to the treating dentist. Attending Dentist's Statement: Also known as the ADA Dental Claim Form. A form used to report dental procedures to a third-party payer, the claim form was developed by the American Dental Association. Audit: An examination of records or accounts to check their accuracy. A post-treatment record review or clinical examination to verify information reported on claims. Bad Faith Insurance Practices: The failure to deal with a beneficiary of a dental benefit plan fairly and in good faith; an activity which impairs the right of the beneficiary to receive the appropriate benefits of a dental benefit plan or to receive them in a timely manner. Some examples of bad faith insurance practices include: evaluating claims based on standards which are significantly at variance with the standards of the community; failure to properly investigate a claim for benefits; and unreasonably and purposely delaying and/or withholding payment of a claim. Balance Billing: Billing a patient for the difference between the dentist's actual charge and the amount reimbursed under the patient's dental benefit plan. Beneficiary: A person who receives benefits under a dental benefit contract. (See also covered person, insured, member, subscriber.) Benefit: The amount payable by a third party toward the cost of various covered dental services or the dental service or procedure covered by the plan. Benefit Booklet: A booklet or pamphlet provided to the subscriber which contains a general explanation of the benefits and related provisions of the dental benefit program. Also known as a "Summary Plan Description." Benefit Plan Summary: The description or synopsis of employee benefits required by ERISA to be distributed to the employees. Birthday Rule: Coordination of benefits regulation stipulating that the primary payer of benefits for dependent children is determined by the parents date of birth. Regardless of which parent is older, the dental benefit program of the parent whose date of birth falls first in a calendar year is considered primary. (May not apply to "self-funded" programs). Bundling of Procedures: The systematic combining of distinct dental procedures by third-party payers that results in a reduced benefit for the patient/beneficiary. By Report: a narrative description used to report a service that does not have a procedure code or is specified in a code as "by report"; may be requested by a third-party payer to provide additional information for claims processing. Cafeteria Plan: Employee benefit plan in which employees select their medical insurance coverage and other nontaxable fringe benefits from a list of options provided by the employer. Cafeteria plan participants may receive additional, taxable cash compensation if they select less expensive benefits. Capitation: A
capitation program is one in which a dentist or dentists contract
with the programs' sponsor or administrator to provide all or
most of the dental services covered under the program to subscribers
in return for payment on a per-capita basis. Case Management: The monitoring and coordination of treatment rendered to patients with specific diagnoses or requiring high cost or extensive services. Certificate Holder: 1) The person, usually the employee, who represents the family unit covered by the dental benefit program; other family members are referred to as "dependents." 2) Generally refers to a subscriber of a traditional indemnity program. 3) In reference to the program for dependents of active-duty military personnel, the certificate holder is called the sponsor. (See Subscriber.) Claim: 1) A request for payment under a dental benefit plan. 2) A statement listing services rendered, the dates of services, and itemization of costs. Includes a statement signed by the beneficiary and treating dentist that services have been rendered. The completed form serves as the basis for payment of benefits. Claimant: Person who files a claim for benefits. May be the patient or the certificate holder. Claim Form: The form used to file for benefits under a dental benefit program; includes sections for the patient, and the dentist to complete. Claims Payment Fraud: The intentional manipulation or alteration of facts submitted by a treating dentist resulting in a lower payment to the beneficiary and/or the treating dentist than would have been paid if the manipulation had not occurred. Claims Reporting Fraud: The intentional misrepresentation of material facts concerning treatment provided and/or charges made, in that this misrepresentation would cause a higher payment. Closed Panel:
A closed panel dental benefit plan exists when patients eligible
to receive benefits can receive them only if services are provided
by dentists who have signed an agreement with the benefit plan
to provide treatment to eligible patients. As a result of Coinsurance: A provision of a dental benefit program by which the beneficiary shares in the cost of covered services, generally on a percentage basis. The percentage of a covered dental expense that a beneficiary must pay (after the deductible is paid). A typical coinsurance arrangement is one in which the third party pays 80% of the allowed benefit of the covered dental service and the beneficiary pays the remainder of the charged fee. Percentages vary and may apply to table of allowance plans; usual, customary, and reasonable plans; and direct reimbursement programs. Consolidated Omnibus Budget Reconciliation Act (COBRA): Legislation relative to mandated benefits for all types of employee benefit plans. The most significant aspects within this context are the requirements for continued coverage for employees and/or their dependents for 18 months who would other-wise lose coverage (30 months for dependents in the event of the employee's death). Contract: Legally enforceable agreement between two or more individuals or entities which confers rights and duties on the parties. Common types of contracts include; 1) contracts between a dental benefit organization and an individual dentist to provide dental treatment to members of an alternative benefit plan. These contracts define the dentist's duties both to beneficiaries of the dental benefit plan and the dental benefit organization, and usually define the manner in which the dentist will be reimbursed; and 2) contracts between a dental benefit organization and a group plan sponsor. These contracts typically describe the benefits of the group plan and the rates to be charged for those benefits. Contract Dentist: A practitioner that contractually agrees to provide services under special terms, conditions and financial reimbursement arrangements. Contract Fee Schedule Plan: A dental benefit plan in which participating dentists agree to accept a list of specific fees as the total fees for dental treatment provided. Contract Practice: Dental practice in which an employer or third-party administrator contracts directly with a dentist or group of dentists to provide dental services for beneficiaries of a plan. (See Closed Panel). Contract Term: The
period of time, usually 12 months, for which a contract is written. Coordination of Benefits (COB): A method of integrating benefits payable for the same patient under more than one plan. Benefits from all sources should not exceed 100% of the total charges. Copayment:
Beneficiary's share of the dentist's fee after the benefit plan
has paid. Cost Sharing: The share of health expenses that a beneficiary must pay, including the deductibles, copayments, coinsurance, and charges over the amount reimbursed by the dental benefit plan. Coverage:
Benefits available to an individual covered under a dental benefit
plan. Covered Person: An individual who is eligible for benefits under a dental benefit program. Covered Services: Services for which payment is provided under the terms of the dental benefit contract. Current Dental Terminology (CDT): A listing of descriptive terms and identifying codes published by the American Dental Association (ADA) for reporting dental services and procedures to dental benefit plans. Current Procedural Terminology (CPT): A listing of descriptive terms and identifying codes developed by the American Medical Association (AMA) for reporting practitioner services and procedures to medical plans and Medicare. Customary Fee: The fee level determined by the administrator of a dental benefit plan from actual submitted fees for a specific dental procedure to establish the maximum benefit payable under a given plan for that specific procedure. (See also Usual Fee and Reasonable Fee.) Deductible: The amount of dental expense for which the beneficiary is responsible before a third party will assume any liability for payment of benefits. Deductible may be an annual or one-time charge, and may vary in amount from program to program. (See Family Deductible.) Dental Benefit Organization: Any organization offering a dental benefit plan. Also known as dental plan organization. Dental Benefit Plan: Entitles covered individuals to specified dental services in return for a fixed, periodic payment made in advance of treatment. Such plans often include the use of deductibles, coinsurance, and/or maximums to control the cost of the program to the purchaser. Dental Benefit Program: The specific dental benefit plan being offered to enrollees by the sponsor. Dental Insurance: A plan that financially assists in the expense of treatment and care of dental disease and accidents to teeth. Dental Prepayment: A method of financing the cost of dental services prior to their receipt. Dental Service Corporation: A legally constituted, not-for-profit organization that negotiates and administers contracts for dental care. Delta Dental Plans and Blue Cross/Blue Shield Plans are such plans. Dependents: Generally spouse and children of covered individual, as defined by terms of the dental benefit contract. Direct Billing: A process whereby the dentist bills a patient directly for his/her fees. Direct Reimbursement: A self-funded program in which the individual is reimbursed based on a percentage of dollars spent for dental care provided, and which allows beneficiaries to seek treatment from the dentist of their choice. Downcoding: A practice of third-party payers in which the benefit code has been changed to a less complex and/or lower cost procedure than was reported. DRGs (Diagnosis-Related Groups): A system of classifying hospital patients on the basis of diagnosis, consisting of distinct groupings. A DRG assignment to a case is based on the patient's 1) principal diagnosis; 2) treatment procedures performed; 3) age; 4) gender; 5) discharge status. Dual Choice Program: A benefit package from which an eligible individual can choose to enroll in either an alternative dental benefit program or a traditional dental benefit program. Eligibility Date: The date an individual and/or dependents become eligible for benefits under a dental benefit contract. Often referred to as effective date. Eligible Person: (See Beneficiary) Enrollee: Individual covered by a benefit plan.(See Beneficiary). Employment Retirement Income Security Act (ERISA): A federal act, passed in 1974, that established new standards and reporting/disclosure requirements for employer-funded pension and health benefit programs. To date, self-funded health benefit plans operating under ERISA have been held to be exempt from state insurance laws. This exemption is currently under review. Exclusions: Dental services not covered under a dental benefit program. Exclusive Provider Organization (EPO): A dental benefit plan that provides benefits only if care is rendered by institutional and professional providers with whom the plan contracts (with some exceptions for emergency and out-of-area services). Expiration Date: 1) The date on which the dental benefit contract expires. 2) The date and individual ceases to be eligible for benefits. Explanation of Benefits: A written statement to a beneficiary, from a third-party payer, after a claim has been reported, indicating the benefit/charges covered or not covered by the dental benefit plan. Extension of Benefits: Extension of eligibility for benefits for covered services, usually designed to ensure completion of treatment commenced prior to the expiration date. Duration is generally expressed in terms of days. Family Deductible: A deductible that is satisfied by combined expenses of all covered family members. For example, a program with $25 deductible may limit its application to a maximum of three deductibles, or $75 for the family, regardless of the number of family members. (See Deductible.) Fee-for-Service: A method of paying practitioners on a service-by-service rather than a salaried or capitated basis. Fee Schedule: A list of the charges established or agreed to by a dentist for specific dental services. Flexible Benefits: A benefit program in which an employee has a choice of credits or dollars for distribution among various benefit options, e.g., health and disability insurance, dental benefits, child care, or pension benefits. (See Cafeteria Plans; Flexible Spending Account). Flexible Spending Account: Employee reimbursement account primarily funded with employee designated salary reductions. Funds are reimbursed to employee for health care (medical and/or dental), dependent care, and/or legal expenses, and are considered a nontaxable benefit. Franchise Dentistry: Refers to a system for marketing a dental practice, usually under a trade name, where permitted by state laws. In return for a financial investment or other consideration, participating dentists may also receive the benefits of media advertising, a national referral system, and financial and management consultation. Freedom of Choice: A provision in a dental benefit program that permits the insured to choose any licensed dentist to provide his or her dental care and receive full benefits under the program. Gate Keeper System: A managed care concept used by some alternative benefit plans, in which enrollees select a primary care dentist, usually a general practitioner or pediatric dentist, who is responsible for providing nonspecialty care and managing referrals, as appropriate, for specialty and ancillary care. Health Maintenance Organization (HMO): A legal entity that accepts responsibility and financial risk for providing specified services to a defined population during a defined period of time at a fixed price. An organized system of health care delivery that provides comprehensive care to enrollees through designated providers. Enrollees are generally assessed a monthly payment for heath care services and may be required to remain in the program for a specified amount of time. Hold Harmless Clause: A contract provision in which one party to the contract promises to be responsible for liability incurred by the other party. Hold harmless clauses frequently appear in the following contexts: 1) Contracts between dental benefit organizations and an individual dentist often contain a promise by the dentist to reimburse the dental benefit organization for any liability the organization incurs because of dental treatment provided to beneficiaries of the organization's dental benefit plan. This may include a promise to pay the dental benefit organization's attorney fees and related costs; and 2) Contracts between dental benefit organizations and a group plan sponsor may include a promise by the dental benefit organization to assume responsibility for disputes between a beneficiary of the group plan and an individual dentist when the dentist's charge exceeds the amount the organization pays for the service on behalf of the beneficiary. If the dentist takes action against the patient to recover the difference between the amount billed by the dentist and the amount paid by the organization, the dental benefit organization will take over the defense of the claim and will pay any judgments and court costs. Incentive Program: A
dental benefit program that pays an increasing share of the treatment
cost, provided that the covered individual utilizes the benefits
of the program during each incentive period (usually a year) and
receives the treatment prescribed. Indemnification Schedule: See Table of Allowances. Indemnity Plan: A dental plan where a third-party payer provides payment of an amount for specific services, regardless of the actual charges made by the provider. Payment may be made either to enrollees or, by assignment, directly to dentists. Schedule of allowances, table of allowances, or reasonable and customary plans are examples of indemnity plans. Individual Practice Association (IPA): A legal entity organized and operated on behalf of individual participating dentists for the primary purpose of collectively entering into contracts to provide dental services to enrolled populations. Dentists may practice in their own offices and may provide care to patients not covered by the contract as well as IPA patients. Insurer: An organization that bears the financial risk for the cost of defined categories or services for a defined group of beneficiaries. (See Third Party.) Insured: Person covered by the program. (See Beneficiary.) International Classification of Diseases (ICD): Diagnostic codes designed for the classification of morbidity and mortality information for statistical purposes, and for the indexing of hospital records by disease and operations, for data storage and retrieval. Least Expensive Alternative Treatment (LEAT): A limitation in a dental benefit plan that will only allow benefits for the least expensive treatment. Also referred to as Least Expensive Professionally Acceptable Alternative Treatment (LEPAAT). Liability: An obligation for a specified amount or action. Limitations: Restrictive conditions stated in a dental benefit contract, such as age, length of time covered, and waiting periods, which affect an individual's or group's coverage. The contract may also exclude certain benefits or services, or it may limit the extent or conditions under which certain services are provided. (See exclusions.) Managed Care: Refers to a cost containment system that directs the utilization of health benefits by:
Maximum Allowance: The maximum dollar amount a dental program will pay toward the cost of a dental service as specified in the program's contract provisions, e.g., UCR, Table of Allowances. Maximum Benefit: The maximum dollar amount a program will pay toward the cost of dental care incurred by an individual or family in a specified period, usually a calendar year. Maximum Fee Schedule: A compensation arrangement in which a participating dentist agrees to accept a prescribed sum as the total fee for one or more covered services. Medicaid: A federal assistance program established as Title XIX under the Social Security Act of 1965 which provides payment for medical care for certain low income individuals and families. The program is funded jointly by the state and federal governments and administered by states. Medically Necessary Care: The reasonable and appropriate diagnosis, treatment, and follow-up care (including supplies, appliances and devices) as determined and prescribed by qualified, appropriate health care providers in treating any condition, illness, disease, injury, or birth developmental malformations. Care is medically necessary for the purpose of: controlling or eliminating infection, pain, and disease; and restoring facial configuration or function necessary for speech, swallowing or chewing. Medicare: A federal insurance program enacted in 1965 as Title XVIII of the Social Security Act that provides certain inpatient hospital services and physician services for all persons age 65 and older and eligible disabled individuals. The program is administered by the Health Care Financing Administration. Member: An individual enrolled in a dental benefit program. (See Beneficiary.) Necessary Treatment: A necessary dental procedure or service as determined by a dentist, to either establish or maintain a patient's oral health. Such determinations are based on the professional diagnostic judgment of the dentist, and the standards of care that prevail in the professional community. Noncontributory Program: A method of payment for group coverage in which all of the monthly premium for the program is paid by the sponsor. Nonduplication of Benefits: This may apply if a subscriber is eligible for benefits under more than one plan. A dental benefit contract provision relieving the third-party payer of liability for cost of services if the services are covered under another program. Distinct from a coordination of benefits provision, because reimbursement would be limited to the greater level allowed by the two plans, rather than a total of 100% of the charges. Also referred to as "benefit-less-benefit" or "carve-out." Nonparticipating Dentist: Any dentist who does not have a contractual agreement with a dental benefit organization to render dental care to members of a dental benefit program. Open Enrollment: The annual period in which employees can select from a choice of benefit programs. Open Panel: A dental benefit plan characterized by three features: 1) Any licensed dentist may elect to participate. 2) The beneficiary may receive dental treatment from among all licensed dentists, with the corresponding benefits being payable to either the beneficiary or the dentist. 3) The dentist may accept or refuse any beneficiary. Overbilling: Nondisclosure of waiver of patient copayment. Overcoding: Reporting a more complex and/or higher cost procedure than was actually performed. Participating Dentist: Any dentist who has a contractual agreement with a dental benefit organization to render care to eligible persons. Payer: In health care, generally refers to entities, other than the patient, that finance or reimburse the cost of health services. In most cases, refers to insurance carriers, other third-party payers, and/or health plan sponsors (employers or unions). Peer Review: 1) A retrospective consideration or an examination by one or more individuals of equal standing or rank. 2) A process established to provide for review by licensed dentists of: the care provided by a dentist for a single patient; disputes regarding fees; cases submitted by carriers, initiated by patients or dentists; quality of care and appropriateness of treatment. Peer Review Organization (PRO): An organization established by an amendment of the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA), to provide for the review of medical services furnished primarily in a hospital setting and/or in conjunction with services provided under the Medicare and Medicaid programs. In addition to their review and monitoring functions, these entities can invoke sanctions, penalties, or other corrective actions for noncompliance in organization standards. Percentile: The number in a frequency distribution below which a certain percentage of fees will fall. For example, the 90th percentile is the number that divides the distribution of fees into the lower 90% and the upper 10%, or that fee level at which 90% of dentists charge that amount or less, and 10% charge more. Point of Service: Arrangement in which patients with a managed care dental plan have the option of seeking treatment from an out-of-network" provider. The reimbursement for the patient is usually based on a low table of allowances, with significantly reduced benefits than if the patient had selected an "in-network" provider. Post-treatment Review: See Audit. Preauthorization: Statement by a third-party payer indicating that proposed treatment will be covered under the terms of the benefit contract. See also precertification, predetermination. Precertification: Confirmation by a third-party payer of a patient's eligibility for coverage under a dental benefit program. See also preauthorization, predetermination. Predetermination: An administrative procedure that may require the dentist to submit a treatment plan to the third party before treatment is begun. The third party usually returns the treatment plan indicating one or more of the following: patient's eligibility, guarantee of eligibility period, covered services, benefit amounts payable, application of appropriate deductibles, copayment and/or maximum limitation. Under some programs, predetermination by the third party is required when covered charges are expected to exceed a certain amount, such as $200. Also known as preauthorization, precertification, pretreatment review, prior authorization. Pre-existing Condition: Oral health condition of an enrollee which existed before his/her enrollment in a dental program. Preferred Provider Organization (PPO): A formal agreement between a purchaser of a dental benefit program and a defined group of dentists for the delivery of dental services to a specific patient population, as an adjunct to a traditional plan, using discounted fees for cost savings. Prefiling of Fees: The submission of a participating dentist's usual fees to a service corporation for the purpose of establishing, in advance, that dentist's usual fees and the customary ranges of fees in a geographic area to determine benefits under a usual, customary, and reasonable dental benefit program. Premium: The amount charged by a dental benefit organization for coverage of a level of benefits for a specified time. Prepaid Dental Plan: A method of financing the cost of dental care for a defined population, in advance of receipt of services. Prepaid Group Practice: See Closed Panel. Pretreatment Estimate: See Predetermination. Prevailing Fee: Term used by some dental benefit organizations to refer to the fee most commonly charged for a dental service in a given area. Preventive Dentistry: Refers to the procedures in dental practice and health programs which prevent the occurrence of oral diseases. Prior Authorization: See Predetermination. Proof of Loss: Verification of services rendered expenses incurred by the submission of claim forms, radiographs, study models, and/or other diagnostic material. Prospective Review: Prior assessment by a payer or payer's agent that proposed services are appropriate for a particular patient, and/or the patient and the category of service are covered by a benefit plan. (See preauthorization, precertification, predetermination, second-opinion program.) Purchaser: Program sponsor, often employer or union, that contracts with the dental benefit organization to provide dental benefits to an enrolled population. Quality Assessment:
The measure of the quality of care provided in a particular setting Reasonable and Customary (R&C) Plan: A dental benefit plan that determines benefits based only on "Reasonable and Customary" fee criteria. (See Usual Fee, Customary Fee, and Reasonable Fee.) Reasonable Fee: The fee charged by a dentist for a specific dental procedure that has been modified by the nature and severity of the condition being treated and by any medical or dental complications or unusual circumstances, and therefore may differ from the dentist's "usual" fee or the benefit administrator's "customary" fee. Reimbursement: Payment made by a third party to a beneficiary or to a dentist on behalf of the beneficiary, toward repayment of expenses incurred for a service covered by the contractual arrangement. Reinsurance: Insurance for third-party payers to spread their risk for losses (claims paid) over a specified dollar amount. Relative Value System: Coded listing of professional services with unit values to indicate relative complexity as measured by time, skill, and overhead costs. Third-party payers typically assign a dollar value per unit to calculate provider reimbursement. Retail Store Dentistry: Refers to dental services offered within a retail, department or drug store operation. Typically, space is leased from the store by a separate administrative group that, in turn, subleases to a dentist or dental group providing the actual dental services. The dental operation generally maintains the same hours of operation as the store and appointments often are not necessary. Considered to be a type of practice, not a dental benefit plan model. Retrospective Review: A post-treatment assessment of services on a case-by-case or aggregate basis after the services have been performed. Risk Pool: A portion of provider fees or capitation payments withheld as financial reserves to cover unanticipated utilization of services in an alternative benefit plan. Schedule of Allowances: See Table of Allowances. Schedule of Benefits: A listing of the services for which payment will be made by a third-party payer, without specification of the amount to be paid. Second-Opinion Program: An opinion about the appropriateness of a proposed treatment provided by a practitioner other than the one making the original recommendation; some benefit plans require such opinions for selected services. Self Funding: The method of providing employee benefits, in which the sponsor does not purchase conventional insurance, but rather elects to pay for the claims directly, generally through the services of a TPA. Self-funded programs often have stop loss insurance in place to cover abnormal risks. Self Insurance: Setting aside of funds by an individual or organization to meet anticipated dental care expenses or its dental care claims, and accumulation of a fund to absorb fluctuations in the amount of expenses or claims. The funds set aside or accumulated are used to provide dental benefits directly instead of purchasing coverage from an insurance carrier. Service Corporations: Dental benefit organizations established under not-for-profit state statutes for the purpose of providing health care coverage, e.g., Delta Dental Plans, Blue Cross and Blue Shield Plans. Statistically-based Utilization Review: A system that examines the distribution of treatment procedures based on claims information and in order to be reasonably reliable, the application of such claims analyses of specific dentists should include data on type of practice, dentist's experience, socioeconomic characteristics, and geographic location. Stop-Loss: A general term referring to that category of coverage that provides insurance protection (reinsurance) to an employer for a self-funded plan. Subscriber: The person, usually the employee, who represents the family unit in relation to the dental benefit program. This term is most commonly used by service corporation plans. Also known as: certificate holder, enrollee. Summary Plan Description: See Benefit Plan Summary. Surcharge: A stated dollar amount paid to the dentist by the beneficiary, in addition to other reimbursement received by third-party payer(s). Table of Allowances: A list of covered services with an assigned dollar amount that represents the total obligation of the plan with respect to payment for such service, but does not necessarily represent the dentist's full fee for that service. Also known as schedule of allowances, indemnity schedule. Termination Date: See Expiration Date. Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA): Legislation (Public Law 97-248) affecting health maintenance organizations and the Medicare and Medicaid programs. Provides regulations for the development of HMO risk contracting with the Medicare program and, through amendment, established new provisions for the foundation and operation of peer review organizations. Third Party: The party to a dental benefit contract that may collect premiums, assume financial risk, pay claims, and/or provide other administrative services. Also known as administrative agent, carrier, insurer, underwriter. Third-Party Administrator (TPA):
Claims payer who assumes responsibility for administering health
benefit plans without assuming any financial risk. Some commercial
insurance carriers and Blue Cross/Blue Shield plans also have
TPA operations to accommodate self-funded employers seeking administrative
services only (ASO) contracts. Unbundling of Procedures: The separating of a dental procedure into component parts with each part having a charge so that the cumulative charge of the components is greater than the total charge to patients who are not beneficiaries of a dental benefit plan for the same procedure. Upcode: Using a procedure code which reflects a higher intensity service than would normally be used for the services delivered. Usual, Customary and Reasonable (UCR) Plans: A dental benefit plan that determines benefits based on "Usual, Customary, and Reasonable" fee criteria. (See Usual Fee, Customary Fee, and Reasonable Fee.) Usual Fee: The fee that an individual dentist most frequently charges for a given dental services. (See also Customary Fee and Reasonable Fee.) Utilization: 1) The extent to which the members of a covered group use a program over a stated period of time; specifically measured as a percentage determined by dividing the number of covered individuals who submitted one or more claims by the total number of covered individuals. 2) An expression of the number and types of services used by the members of a covered group over a specified period of time. Utilization Management: Is a set of techniques used by or on behalf of purchasers of health care benefits to manage the cost of health care prior to its provision by influencing patient care decision-making through case-by-case assessments of the appropriateness of care based on accepted dental practices. Utilization Review, statistically based: A system that examines the distribution of treatment procedures based on claims information and in order to be reasonably reliable, the application of such claims analyses of specific dentists should include data on type of practice, dentist's experience, socioeconomic characteristics, and geographic location. Waiting Period: The period between employment or enrollment in a dental program and the date when a covered person becomes eligible for benefits.
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