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Benefits Dictionary

Abscess: An inflamed lesion caused by tissue destruction. Dental abscesses often occur when a tooth's nerve dies due to decay or trauma.

ADA: American Dental Association—A professional association for dentists that promotes the integrity and ethics of the profession and provides services through its initiatives in education, research, advocacy, and the development of standards.

Amalgam: An alloy of silver, tin, copper, and mercury; often called silver filling. Dental amalgam is one of the most commonly used materials to fill cavities in back teeth.

Attending Dentist's Statement: see Claim Form. 

Attrition: Wearing down of the surface of a tooth from chewing, grinding, or clenching.

Baby Bottle Tooth Decay: Severe decay in baby teeth caused when young children sleep with a bottle of milk, juice, or other sugary drink. The drink's natural sugars combine with bacteria in the mouth to produce acids that decay teeth.

Balance Billing: Charges a provider makes to an enrollee for the difference between Delta Dental's maximum plan allowance (MPA) and the dentist's fee. Participating dentists agree to accept Delta Dental's MPA as the full fee for covered services and charge the enrollee for copayments and deductibles only.

Beneficiary: see Enrollee. 

Benefit Year: The 12-month period of the dental contract (not always a calendar year). Most group contracts include a maximum benefit available for their enrollees' covered dental services that renews at the beginning of each benefit year (excluding orthodontics, which has a lifetime maximum).

Bitewing Radiograph: An X-ray taken of the back teeth that shows decay between teeth or under fillings.

Bridge: A device used to replace missing teeth. See Partial Denture.

Bruxism: Involuntary clenching or grinding of the teeth.

Calculus: Hard deposits of mineralized material and calcified plaque that builds up on teeth. Also referred to as tartar, it generally requires removal by a dental professional.

Caries: Tooth decay caused by acid-producing bacteria in the mouth that weaken and break down the hard enamel shell.

Certificate of Coverage: A standard booklet provided by Delta Dental to subscribers explaining their benefit coverage.

Claim Form: A statement listing dental services, the dates of services, an itemization of fees, and the treating dentist's information. The completed form is used to request payment from Delta Dental and other companies. Download a printable claim form.

Composite Resin: A tooth-colored material used for fillings and to repair defects in the teeth.

Coordination of Benefits (COB): The order of billing and payments for dental services when an enrollee is covered by more than one dental plan. The total payments cannot exceed 100% of the charged fee(s).

Copayment: The amount or percentage of the total approved amount that the subscriber is obligated to pay.

Covered Person: see Enrollee. 

Covered Service: A dental service that is payable under the terms of the benefit contract.

Crown: 1) The part of the tooth covered by enamel and visible above the gum line; 2) A dental restoration used to restore form and function to a damaged tooth, also called a cap.

Deciduous Teeth: The 20 primary teeth of a child. Also called baby teeth, the deciduous teeth hold the space for the permanent, or secondary, teeth. As the permanent teeth form and begin to move into place in the jaw, the deciduous teeth gradually loosen and fall out.

Deductible: The portion of covered dental expenses the enrollee must pay before the plan's benefits begin.

Denture: A removable appliance used to replace missing teeth. A complete denture replaces all of the upper teeth and/or all the lower teeth, and a partial denture replaces one or more lost teeth.

Dependents: Anyone listed on the contract other than the primary subscriber.

Edentulous: Having no teeth; toothless.

Effective Date: (1) The date a company's or organization's dental contract goes into effect; (2) The date that an individual/family becomes eligible for dental benefit coverage.

Enamel: Hard, calcified outer covering of the crown of a tooth.

Endodontics: The dental specialty concerned with the treatment of the nerve of the tooth.

Enrollee: A person covered under a dental benefit contract.

Exclusion: A dental service or procedure not covered by a benefit contract.

Explanation of Benefits (EOB): A detailed statement of a processed claim sent to the enrollee and participating dentist. It shows procedures, date(s) of service, processing policies, Delta Dental's payment and the amount (if any) that the enrollee owes to the dental provider.

Fee Schedule: A list of the charges established by a benefit provider and agreed to by a dentist for specific dental services.

Fluoride: A chemical compound that strengthens tooth enamel and makes it more resistant to decay.

Gingivitis: Redness and swelling of the gums surrounding the teeth. It is the earliest stage of periodontal disease, usually caused by a buildup of plaque.

Group: The company or organization that contracts with Delta Dental to administer its dental benefit plan. The group determines plan type, benefit levels, maximums, and member eligibility.

Group Member: see Subscriber.

Gum Disease: see Periodontitis.

Halitosis: Bad breath

HIPAA: The Health Insurance Portability and Accountability Act of 1996. This federal law is intended to improve access to health insurance, limit fraud and abuse, and control administrative costs.

Impacted Tooth: An un-erupted or partially erupted tooth that is blocked from fully erupting by another tooth, bone, or soft tissue.

Implant: A device inserted into the jawbone to provide an anchor for replacing missing tooth/teeth.

Inlay: A custom-made filling that is permanently placed in a prepared tooth. Gold and porcelain are commonly used materials for inlays.

Insured: see Enrollee.

Limitations: Conditions, such as age and period of time covered, that restrict a dental program's coverage for certain services. (For example, in most programs, a prophylaxis is a covered benefit twice in a 12-month period.)

Malocclusion: Improper alignment of biting or chewing surfaces of the upper and lower teeth.

Maximum Benefit: The limit set in a dental contract on the total dollar amount a dental plan pays for covered dental services in a specific time frame. For example: $1,000 per enrollee in a calendar year.

Maximum Plan Allowance (MPA): The highest dollar amount Delta Dental pays for a covered service. Participating dentists agree not to charge our enrollees the difference (if any) between the MPA and the dentist's fee for covered services.

Member: see Enrollee.

National Provider Identifier (NPI): A unique identification number used by a health care entity in the electronic transmission of protected Personal Health Information (PHI).

Nonparticipating (Non-Par) Dentist: Any dentist who does not have a contractual agreement with Delta Dental for any or all of our programs.

Nonparticipating Dentist Fee: The maximum reimbursement amount per procedure that Delta Dental pays for services performed by a nonparticipating dentist.

Onlay: A custom-made filling that is permanently placed in a prepared tooth and covers one or more of the tooth's cusps. Gold and porcelain are commonly used materials for onlays.

Optional Services: Procedures that are not covered benefits under the terms of the dental contract. If an enrollee elects to have an optional service, a claim should be submitted, and Delta Dental will review the procedure. If the procedure is an alternative to a covered service, Delta Dental could make payment based on the allowed amount for the covered service.

Oral Surgery: The dental specialty concerned with diagnosis and surgery of diseases, injuries and defects in the mouth, jaw and face.

Orthodontics: The dental specialty concerned with straightening or moving misaligned teeth and/or jaws with braces and/or surgery.

Osseous Surgery: The repair of the bone around and supporting teeth that has been damaged by gum disease.

Partial Denture: A device used to replace missing teeth by attaching artificial teeth to adjacent natural teeth or implants. A fixed partial denture is cemented or otherwise attached, and is also referred to as a fixed bridge. A removable partial denture can be taken in and out by the patient and is also referred to as a removable bridge.

Participating (Par) Dentist: A licensed dentist who has signed an agreement with Delta Dental. He or she agrees to submit claims and accept Delta Dental's payment, which is calculated based on the program in which the dentist participates. Delta Dental sends claim payments directly to the dentist.

Panoramic Radiograph: A large X-ray that shows the teeth, jaws, and surrounding soft and hard tissue.

Pediatric Dentistry: The dental specialty concerned with the comprehensive treatment of children.

Periodontal Disease: Inflammation and loss of connective tissue of the supporting or surrounding structure of the teeth (gum disease).

Periodontics: The dental specialty concerned with diseases, conditions, and treatment of the gums, tissue and bone that supports the teeth.

Plaque: A soft, sticky film that collects on the surface of teeth. The bacteria in plaque can cause decay and gum irritation if not removed by daily brushing and flossing. If left on the teeth, plaque builds up, hardens, and becomes calculus.

Porcelain: A hard, glass-like material that can be tinted to duplicate individual tooth color, and is used in restorations to give the look of a natural tooth.

Pre-treatment Estimate: A treatment plan submitted to Delta Dental for review and estimation of benefits before procedures are started.

Preferred Provider Organization (PPO): A dental benefit plan in which participating dentists agree to accept a list of specific fees as the total fees for dental treatment provided. 

Primary Subscriber: see Subscriber.

Processing Policies: Delta Dental's policies and guidelines used for payment of claims. Processing policies may be amended from time to time. If a processing policy is applied to a billed service, the explanation is included on the statement (EOB) sent to the enrollee and participating dentist.

Prophylaxis: A professional dental cleaning to remove plaque, calculus and stains to help prevent dental disease. Also referred to as a prophy or teeth cleaning.

Prosthodontics: A dental specialty concerned with restoration and/or replacement of missing teeth and other oral structures.

Provider: A dentist or group dental practice.

Radiographs: X-rays of the teeth and areas in and around the mouth that can help dental professionals evaluate and diagnose many diseases and conditions.

Root Canal Therapy: Treatment for disease or inflammation of the pulp or root of a tooth.

Scaling: Using specialized dental instruments to remove plaque, calculus, and stain from the crowns and roots of teeth.

Sealant: A thin plastic material applied to the tooth's biting surface to prevent decay.

Space Maintainer: An appliance that holds teeth in position.

 Subscriber: The employee or participant who is certified by the company or organization (group) providing the dental program as eligible to receive benefit coverage from Delta Dental. If family coverage is offered, the additional people listed on the contract will be designated as spouse or dependent.

Temporomandibular joint: The joint connecting the lower jaw to the skull.

Termination: The date on which the dental benefits contract ends or the date on which the enrollee is no longer eligible for benefits.

Usual Fee: The fee that an individual dentist most frequently charges for a dental service.

Veneers: Thin, pre-shaped shells that cover top or bottom front teeth to repair chips or cracks, fix gaps, and change the shape and size of teeth. They usually are made of porcelain or tooth-colored composite resin material.

Waiting Period: The period of time specified by an employer or group before an employee or group member becomes eligible to receive benefits.