Glossary

A

Abscess

A localized inflammation due to a collection of pus in the bone or soft tissue, usually caused by an infection.

Abutment

A tooth or implant used to support a prosthesis. A crown unit used as part of a fixed bridge.

Accreditation

Certification that an organization meets the reviewing organization's standards. Examples: accreditation of HMOs by the National Committee on Quality Assurance (NCQA) or accreditation of hospitals by the Joint Commission of Accreditation of Healthcare Organizations (JCAHO).

Adjudication

The administrative procedure used to process a claim for service according to the covered benefit.

Active, Full-time Employee

An employee must work for the employer on a regular basis in the usual course of the employer's business to be considered an active, full-time employee and eligible for coverage. Usually, a minimum number of hours of regular work is specified.

Administrative Services Only (ASO)

An arrangement between an insurer and an employer in which an insurer provides administrative services to an employer's health benefits plan. These services typically include processing claims -- but may be more limited. In an ASO arrangement the insurer typically does not insure the risk of paying benefits to members/enrollees. A common rule of thumb is that for an employer to consider an ASO arrangement they must have at least 100 employees.

Allowable Charge

The maximum fee that a health plan will reimburse a provider for a given service.

Alternative Birthing Center

A facility offering a "non-traditional" ("not like a hospital") setting for giving birth. While alternative birthing centers can range from free-standing centers to special areas within hospitals, birthing centers are generally known for a more comfortable, home-like atmosphere, allow more participation by the father and have more procedural flexibility than commonly found in hospital births.

Amalgam

A dental filling material, composed of mercury and other minerals, used to fill decayed teeth.

Alveoloplasty

A surgical procedure used to recontour the supporting bone structures in preparation of a complete or partial denture.

Ambulatory Care

A general term for care that doesn't involve admission to an inpatient hospital bed. Visits to a doctor's office are a type of ambulatory care. Ambulatory Surgery

Surgical procedures performed that do not require an overnight hospital stay. Procedures can be performed in a hospital or a licensed surgical center. Also called Outpatient Surgery.

American Dental Association (ADA)

A professional association of dentists dedicated to serving the public and profession of dentistry.

American Medical Association (AMA)

A professional association of physicians dedicated to promoting the art and science of medicine and the betterment of public health.

Ancillary care: Diagnostic and/or supportive services such as radiology, physical therapy, pharmacy or laboratory work.

Anesthetic

A class of drugs that eliminates or reduces pain. See local anesthetic.

Anniversary date

The day after a coverage period ends under a health benefits plan. Usually, the month and day that a health benefits plan first goes into effect becomes its anniversary date each year.

Annual out-of-pocket maximum

The most a plan member will pay per year for covered health expenses before the plan pays 100% of covered health expenses for the rest of that year.

Anterior

Refers to the teeth and tissues located towards the front of the mouth (upper or lower incisors and canines).

Apex

The tip or end of the root of the tooth.

Apicoectomy

The amputation of the apex of a tooth.

Appeals

A process available to the patient, their family member, treating provider or authorized representative to request reconsideration of a previous adverse determination.

Assignment of benefits

When a covered person authorizes his or her health benefits plan to directly pay a health care provider for covered services. Traditional health insurance pays benefits directly to the covered person.

Authorization:

See Precertification.

B

Behavioral care services

Assessment and therapeutic services used in the treatment of mental health and substance abuse problems.

Beneficiary

A person who is eligible to receive benefits under a health benefits plan. Sometimes "beneficiary" is used for eligible dependents enrolled under a benefits plan; "beneficiary" can also be used to mean any person eligible for benefits, including both employees and eligible dependents.

Benefit Percentage

The benefit is usually determined as a percentage of the employee's pre-disability income up to an overall maximum benefit amount.

Benefit year

The coverage period, usually 12 months long, which is used for administration of a health benefits plan.

Benefits

The portion of the costs of covered services paid by a health plan. For example, if a plan pays the remainder of a doctor's bill after an office visit copayment has been made, the amount the plan pays is the "benefit." Or, if the plan pays 80% of the reasonable and customary cost of covered services, that 80% payment is the "benefit."

Benefits package

A term informally used to refer to the employer's benefits plan or to the benefits plan options from which the employee can choose. "Benefits package" highlights the fact a health benefits plan is a compilation of specific benefits.

Bicuspid

A two-cusped tooth found between the molar and the cuspid also known as an eye tooth or canine tooth.

Biopsy

A process of removing tissue to determine the existence of pathology.

Bitewing x-rays

X-rays taken of the crowns of teeth to check for decay.

Bleaching

The technique of applying a chemical agent, usually hydrogen peroxide, to the teeth to whiten them.

Board-certified

Any physician who has completed medical school, internship and residency in his or her chosen specialty and has successfully completed an examination conducted by a group (or board) of peers.

Bonding

A process to chemically etch the tooth's enamel to better attach (bond) composite filling material, veneers, or plastic/acrylic.

Bone loss

The breakdown and loss of the bone that supports the teeth, usually caused by infection or long-term occlusal (chewing areas of the teeth) stress.

Brand-name drug

A drug manufactured by a pharmaceutical company which has chosen to patent the drug's formula and register its brand name.

Bridge

A nonremovable restoration that is used to replace missing teeth.

Brush biopsy

Brush biopsy is a painless procedure used to gather cells in the mouth. The dentist uses a small brush to take a tissue specimen, which is then sent to a laboratory for analysis to determine the presence of pre-cancerous or early stage cancerous cells. Laboratory results are used to determine the need for further procedures.

Bruxism

The involuntary clenching or grinding of the teeth.

C

Calculus

The hard deposit of mineralized plaque that forms on the crown and/or root of the tooth. Also referred to as tartar.

Canine tooth

The second tooth from the big front tooth, commonly called the eye tooth or cuspid.

Cap

Another term for crown; usually referring to a crown for a front tooth.

Care management

A generic term which has been used in many different ways. One definition refers to processes that take a global approach to medical care from prevention through treatment and recovery.

Caries

The correct technical term for decay which is the progressive breaking down or dissolving of tooth structure, caused by the acid produced when bacteria digest sugars.

Carrier

A term historically used for licensed insurance companies, although now is sometimes used to include both licensed insurers and HMOs.

Case management

Coordination of services to help meet a patient's health care needs, usually when the patient has a condition which requires multiple services from multiple providers. This term is also used to refer to coordination of care during and after a hospital stay.

Cavity

A layman's term for tooth decay. Also, the dental term for the hole that is left after decay has been removed.

CDHP (consumer-driven health plan)

A health care model in which the consumer (plan member) is made aware of the true costs and value of health care so that he/she can make informed decisions that balance choice with cost. Health plans that fall in this category may include FSA, HSA and HRA.

Cement

A special type of glue used to hold a crown in place. It also acts as an insulator to protect the tooth's nerve.

Cementum

The very thin, bonelike structure that covers the root of the tooth.

Certification

See Precertification.

Charge Amount

The amount billed by a provider for services rendered to a participant.

Chemotherapy

Treatment of malignant disease by chemical or biological antinoeplastic agents.

Claim

A claim is a request for payment under the terms of a health benefits plan.

Claim Status

Claims are Paid, Pended, Denied, or Received-Not-Yet-Processed.

Clenching

The forceful holding together of the upper and lower teeth, which places stress on the ligaments that hold the teeth to the jawbone and the lower jaw to the skull.

Clinical Practice Guidelines

General procedures and suggestions about what constitutes an acceptable range of practices for particular diseases or conditions. These guidelines are usually developed by a consensus of doctors in a given field, such as radiology or cardiology.

Cognitive service

Diagnostic services a doctor provides during delivery of medical services, consultations or care.

Coinsurance

The portion of eligible expenses that plan members are responsible paying, most often after the deductible is met. It's usually determined as a percentage of the total cost.

Complex rehabilitation

The extensive dental restoration involving 6 or more units of crown and/or bridge in the same treatment plan. Using full crowns and/or fixed bridges which are cemented in place, the your dentist will rebuild natural teeth, fill in spaces where teeth are missing and establish conditions which allow each tooth to function in harmony with the occlusion (bite). The extensive procedures involved in complex rehabilitation require an extraordinary amount of time, effort, skill and laboratory collaboration for a successful outcome.

Composite

A tooth-colored filling made of plastic resin or porcelain.

Consolidated Omnibus Budget Reconciliation Act (COBRA)

A federal statute that requires most employers to offer to covered employees and covered dependents who would otherwise lose health coverage for reasons specified in the statute, the opportunity to purchase the same health benefits coverage that the employer provides to its remaining employees. This continuation of coverage can only last for a maximum specified period of time (usually 18 months for employees and dependents who would otherwise lose coverage due to loss of employment or work hour reduction, or 36 months for dependents who would lose coverage for certain reasons other than employment loss by the employee).

Consultation

A discussion with another health care professional when additional feedback is needed during diagnosis or treatment. Usually, a consultation is by referral from a primary care physician.

Contract

A legal agreement between an individual subscriber or an employer group and a health plan that describes the benefits and limitations of the coverage.

Conversion Option

The option to purchase individual coverage by a person who will no longer have access to group health insurance.

Coordination of Benefits

A provision in a contract that applies when a person is covered under more than one group health benefits program. It requires that payment of benefits be coordinated by all programs to eliminate overinsurance or duplication of benefits.

Copayment (copay)

Amount that a plan member must pay the provider at the time of service, usually after the deductible is met for eligible expenses. It is usually a flat fee of $10 - $25.

Cosmetic dentistry

Any dental treatment or repair that is solely rendered to improve the appearance of the teeth or mouth.

Coverage

The benefits that are provided according to the terms of a participant's specific health benefits plan.

Coverage End Date

Coverage End Date displays the date that coverage ends for a participant. This field is blank, if the participant is considered covered as of the date of the inquiry.

Covered Services

Hospital, medical, and other health care services incurred by the enrollee that are entitled to a payment of benefits under a health benefit contract. The term defines the type and amount of expense that will be considered in the calculation of benefits.

Credentialing

A process that reviews a health care provider's credentials against the credentials required to participate in a managed care network. To participate in a typical provider network, physicians and facilities are credentialed prior to being admitted. Typically they are recredentialed at regular intervals (commonly every two years). Generally, they must meet specific criteria for continued participation in a provider network.

Crown

The portion of a tooth that is covered by enamel. Also a dental restoration that covers the entire tooth and restores it to its original shape.

Crown lengthening

A surgical procedure exposing more tooth for restorative purposes.

Curettage

A deep scaling of that portion of the tooth below the gum line. Purpose is to remove calculus and infected gum tissue.

Cuspid

See canine tooth.

Cusp(s)

The protruding portion(s) of a tooth's chewing surface.

Custodial Care

Care that is provided primarily to meet the personal needs of a patient. The care is not meant to be curative or providing medical treatment.

D

Date of Service

The date the service was provided to the participant as specified on the claim.

Day Treatment Center

An outpatient facility that is licensed to provide outpatient care and treatment, usually for mental or nervous disorders or substance abuse.

DDS

Doctor of Dental Surgery or DMD, Doctor of Dental Medicine. Degrees given to dental school graduates. Both degrees are the same particular dental schools identify at their discretion their graduates as DMD or DDS.

Decay

See caries.

Deciduous

See primary teeth.

Deductible

The dollar amount that a plan member must pay for eligible health expenses before a traditional health plan kicks in with benefits.

Definition of Disability

One of the most important provisions in a disability contract is the definition of disability that will be used to determine an employee's eligibility for benefits.

Definition of Total Disability

One of the most important provisions in a disability contract is the definition of disability that will be used to determine an employee's eligibility for benefits.

Own Occupation (Own Occur)

Under this definition, an employee will be considered disabled only if s/he is unable to perform the duties of his or her occupation.

Any Occupation (Any Occur)

Under this definition, an employee will be considered disabled only if s/he is unable to work in any occupation for which s/he is qualified by education, training, or experience. This is closely related to the definition that the Social Security Administration uses in determining disability.

Definition of Partial/Residual Disability

This definition of disability applies when an employee is able to return to work part-time or even full-time but with a loss of earnings. If the employee is working in this limited capacity and is earning less than a certain level of income, s/he will still be eligible for limited benefits under the plan. Not all disability carriers use this terminology to describe a "part-time" work situation, but most provide some type of benefit to encourage return to work.

Delegation

Delegation is a formal process by which a payer gives another entity the authority to perform the claims payment administration on their behalf.

Denied Claim

Claims that are not issued a bank draft/remittance due to a specific reason code.

Dental floss

A thin, nylon string, waxed or untaxed, that is inserted between the teeth to remove food and plaque.

Dental hygienist

A dental professional specializing in cleaning the teeth by removing plaque, calculus, and diseased gum tissue. He/She acts as the patient's guide in establishing a proper oral hygiene program.

Dentin

The part of the tooth that is under both the enamel which covers the crown and the cemented which covers the root

Denture

A removable appliance used to replace teeth. A complete denture replaces all of the upper teeth and/or all the lower teeth. See also partial denture

Dependent

A person eligible for coverage under an employee benefits plan because of that person's relationship to an employee. Spouses, children and adopted children are often eligible for dependent coverage

Diagnostic Tests

Tests and procedures ordered by a physician to help diagnose or monitor a patient's condition or disease. Diagnostic tools include radiology, ultrasound, nuclear medicine, laboratory and pathology services or tests

Direct pulp cap

The procedure in which the exposed pulp is covered with a dressing or cement that protects the pulp and promotes healing and repair

Discharge planning

Identifying a patient's health care needs after discharge from inpatient care

Disenrollment

Voluntarily terminating one's participation in a health benefits plan

Drug Formulary

See Formulary

Dry socket

A localized inflammation of the tooth socket following an extraction due to infection or loss of a blood clot

Duplicate coverage

When a person has coverage for the same health services under more than one health benefits plan

Durable medical equipment

Equipment that can withstand repeated use and is primarily and usually used to serve a medical purpose, is generally not useful to a person in the absence of illness or injury, and is appropriate for use in the home.

E

Effective Date

The date on which coverage under a health benefits plan begins.

Eligible

Provisions contained in each health benefits plan that specify who qualifies for coverage under that plan.

Elimination Period

This is the period of time between the date the disability begins and the beginning of the benefit payment period. It is the period during which an employee must be disabled before payment of benefits begins. It is sometimes referred to as the Qualifying Period.

Emergency

An accident or sudden illness that a person with an average knowledge of medical science believes needs to be treated right away or it could result in loss of life, serious medical complications or permanent disability. Emergencies are covered by most payers 24 hours a day, seven days a week, no matter where you are. Whenever there's a serious accident or sudden illness, and symptoms are severe and they occur unexpectedly, seek medical help immediately. Examples of emergency situations include: uncontrolled bleeding, seizure or loss of consciousness, shortness of breath, chest pain or squeezing sensations in the chest, suspected overdose of medication or poisoning, sudden paralysis or slurred speech, severe burns, broken bones or severe pain.

Employee Assistance Program (EAP)

An EAP is an assessment and referral program or a short-term counseling program that is pre-purchased by some employers and is available to their employees, their dependents and household members. Visits to the EAP are separate from your behavioral health care benefits plan with no copayment required.

Employee Retirement Income Security Act (ERISA)

Federal legislation that applies to retirement programs and to employee welfare benefit programs established or maintained by employers and unions.

Enamel

The hard, calcified (mineralized) portion of the tooth which covers the crown. Enamel is the hardest substance in the body.

Enzootics

The dental specialty that deals with injuries to or diseases of the pulp, or nerve, of the tooth.

Enrollee

An individual who is enrolled and eligible for coverage under a health plan contract. Also called Member.

Evidence of Insurability

Group disability coverage is generally sold as "guaranteed issue," which means that evidence of insurability is not required.

Exclusions

Specific conditions or services that are not covered under the benefit agreement.

Experimental Procedures

Experimental, investigational or unproven procedures and treatments.

Expiration Date

The date indicated in an insurance contract as the date coverage expires.

Explanation of benefits (EOB)

A statement provided by the health benefits administrator that explains the benefits provided, the allowable reimbursement amounts, any deductibles, coinsurance or other adjustments taken and the net amount paid. A participant typically receives an explanation of benefits with a claim reimbursement check or as confirmation that a claim has been paid directly to the provider.

Extended care facility (ECF)

A medical care institution for patients who require long-term custodial or medical care, especially for chronic disease or a condition requiring prolonged rehabilitation therapy.

Extension of benefits

When a person's coverage is extended under certain conditions, such as disability, after their group health coverage would otherwise have ended.

Excision

Surgical removal of bone or tissue.

Exclusions

There are specific provisions included in group disability plans that preclude coverage in certain situations. Typically, a plan will not pay benefits for disabilities caused by war or a self-inflicted injury.

Exostosis

The overgrowth of normal bone.

Extent of disability

Some policies require that employees be totally disabled before payments begin. Other policies pay out for partial disability for a limited time, but most often only if the partial disability follows a period of total disability for the same cause.

Extracoronal

The outside of the crown of the tooth.

Extraction

The removal of a tooth.

Extraoral

The outside of the mouth.

F

Filling

Material used to fill a cavity or replace part of a tooth.
Flexible benefits plan: A type of benefits program that offers employees a menu of benefit options, allowing them to create a benefits package which best suits their individual needs.

Flexible Spending Account (FSA)

An account that reimburses the participant for qualified health costs or dependent care expenses through one pre-tax savings account. Employees or employers or both fund the account. At the end of each year, unused dollars are forfeited by the account holder.

Floss

See dental floss.

Fluoride

A chemical compound used to prevent dental decay, utilized in fluoridated water systems and/or applied directly to the teeth.

Formulary

A list of preferred, commonly prescribed prescription drugs. These drugs are chosen by a team of doctors and pharmacists because of their clinical superiority, safety, ease of use and cost.

Frenum

Muscle fibers covered by a mucous membrane that attaches the cheek, lips and or tongue to associated dental mucosa.

Frenectomy

The removal of a frenum.

G

Gatekeeper

A primary care physician who provides a broad range of routine medical services and refers patients to specialists, hospitals and other providers as necessary. This traditional primary care physician role is called a "gatekeeper" function. Under some benefits plans, a referral by the primary care physician is required to obtain services from other providers.

Generic drug

A prescription drug that has the same active-ingredient formula as a brand-name drug. A generic drug is known only by its formula name and its formula is available to any pharmaceutical company. Generic drugs are rated by the Food and Drug Administration (FDA) to be as safe and as effective as brand-name drugs and are typically less costly.

Gingiva

The soft tissue that covers the jawbone. Also referred to as the gums.

Gingivectomy

The removal of gingiva (gum).

Gingivitis

An inflammation or infection of the gingiva (gum tissue); the initial stage of gum disease.

Gingivoplasty

A surgical procedure to reshape or repair the gingiva (gum).

Graft

A piece of tissue or synthetic material placed in contact with tissue to repair a defect or supplement a deficiency.

Group health coverage

A health benefits plan that covers a group of people as permitted by state and federal law.

Gum

See gingiva.

Gum disease

See periodontal disease.

H

Health Care Financing Administration (HCFA)

The federal agency responsible for administering Medicare and federal participation in Medicaid.

Health Maintenance Organization (HMO)

An organization that arranges a wide spectrum of health care services which commonly include hospital care, physicians' services and many other kinds of health care services with an emphasis on preventive care.

Health maintenance services

Any health care service or program that helps maintain a person's good health. Health maintenance services include all standard preventive medical practices, such as immunizations and periodic examinations, as well as health education and special self-help programs.

Health plan

A term that has different meanings depending upon the context. "Health plan" can be used to mean an HMO, a health benefits plan provided by an employer to its employees, or a health benefits plan offered to employers by an insurer or third party administrator.

Health Reimbursement Arrangement (HRA) (if selected)

An arrangement in which the participant is reimbursed for covered health expenses by his/her employer up to a predetermined amount. Many HRAs gives the employer flexibility and choice in the way the account is structured and what is covered. It also includes optional incentives for members as well as decision-making tools. Unused amounts may be carried over to the next year, subject to limits set by the employer.

Health Savings Account (HSA) (if selected)

A reimbursement account in which the participant pays for health costs through a fully insured, tax-exempt savings account. Employees or employers or both fund the account. An HSA is subject to regulations mandated by the federal government that limit coverage to IRS section 213(d) medical coverage. All unused amounts carry over indefinitely during a participant's lifetime.

The Health Plan Employer Data and Information Set (HEDIS®)

A core set of performance measures developed through the collaborative effort of the National Committee for Quality Assurance (NCQA), employer groups and health care purchasers.

HEDIS is a registered trademark of the National Committee for Quality Assurance.

High noble metal

See metals, classification of.

HIPAA

Health Insurance Portability and Accountability Act of 1996. The law has several parts: The first part addresses health insurance portability and is designed to protect health insurance coverage for workers and their families when they change or lose their jobs. Another part of the law is designed to reduce the administrative costs of providing and paying for healthcare through standardization. The law also includes requirements to protect the privacy of individuals' protected health information. Health plans, providers and other organizations with access to protected health information are covered by the requirements of HIPAA.

Home Health Care

Health services rendered in the home to an individual who is confined to the home. Such services are provided to individuals who do not need institutional care, but who need nursing services or therapy, medical supplies and special outpatient services.

Hospice

A health care facility that provides supportive care for the terminally ill.

Hospital

An institution whose primary function is to provide diagnostic and therapeutic inpatient services, for a variety of surgical and non-surgical medical conditions. In addition, most hospitals provide outpatient services, including emergency care.

I

ID card

Identification cards are provided to all participants for proper identification under their group health plan. ID card information helps providers verify patient eligibility for coverage.

Immediate denture

A denture constructed for immediate placement after removal of the remaining teeth.

Impacted tooth

An unerupted or partially erupted tooth that is positioned against another tooth, bone or soft tissue so that complete eruption is unlikely.

Impairment

An alteration of health status, assessed by objective medical criteria. This is a medical finding.

Implant

An artificial device, usually made of a metal alloy or ceramic material, that is implanted within the jawbone as a means to attach an artificial crown, denture, or bridge.

Incisors

The four front teeth referred to as central and lateral incisors, located in the upper and lower jaws and used to cut and tear food. The central incisors are the two large teeth in the middle of the mouth and the lateral incisors are next to the central incisor, one on each side.

Indemnity plan

A type of health benefits plan under which the covered person pays 100% of all covered charges up to an annual deductible. The health benefits plan then pays a percentage of covered charges up to an out-of-pocket maximum.

Indirect pulp cap

A procedure in which the nearly exposed pulp is covered with a protective dressing to protect the pulp from additional injury and to promote healing and repair via formation of secondary dentin.

Inlay

A cast gold filling that is used to replace part of a tooth.

In-Network Provider

Any health care provider (physician, hospital, etc.) that belongs to a particular payer's provider network. Staying in-network gives members the advantage of significant discounts, helping to stretch their account dollars further.

Infertility

Term used to describe a condition or the inability to conceive or an inability to carry a pregnancy to a live birth after a year or more of regular sexual relations without the use of contraception.

Infusion Therapy

Treatment accomplished by placing therapeutic agents into the vein, including intravenous feeding. Such therapy also includes enteral nutrition, which is the delivery of nutrients into the gastrointestinal tract by tube.

Inpatient care

Care given to a patient admitted to a hospital, extended care facility, nursing home or other facility.

Interproximal

The area between two adjacent teeth.

Intracoronal

The area within the crown of a tooth.

Intraoral

The inside of the mouth

J

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

The JCAHO is an independent, not-for-profit organization whose mission is to improve the quality of care provided to the public through the provision of health care accreditation and related services which support performance improvements in health care organizations. The Joint Commission evaluates and accredits hospitals and health care organizations which provide managed care (including health plans, preferred provider organizations and integrated delivery systems), home care, long-term care, behavioral health care, laboratory and ambulatory care services.

K

no k items

L

Labial

The area pertaining to or around the lip.

Limitations

There may be specific provisions included in group disability plans that limit coverage in certain situations. Often only limited benefits are payable for specific conditions or under specific circumstances (for example, mental illness and pre-existing conditions). See also "Mental Illness Limitations" and "Pre-Existing Limitations."

Lingual

The area pertaining to or around the tongue.

Local anesthetic

The injection given in the mouth to numb the areas where a tooth or area needs a dental procedure. Often referred to as novocaine.

Long-term care

The range of services typically provided at skilled nursing, intermediate-care, personal care or elder-care facilities.

M

Maintenance medication

Medications that are prescribed for long-term treatment of chronic conditions, such as diabetes, high blood pressure or asthma.

Malocclusion

The improper alignment of biting or chewing surfaces of upper and lower teeth.

"Mandatory" Rehabilitation

A "mandatory" rehabilitation provision encourages disabled employees to participate in rehabilitation efforts whenever appropriate. Such a provision allows for termination of benefits if the employee refuses to cooperate or participate with a rehabilitation plan.

Mandible

The lower jaw.

Managed Care

A system of health care delivery that manages the cost of health care and access to health care providers.

Maryland bridge

The trade name that has become synonymous with any resin bonded fixed partial denture (bridge).

Mastication

The act of chewing.

Maxilla

The upper jaw.

Maximum Benefit Period (Benefit Duration)

This is the maximum length of time for which benefits are payable under the plan as long as the employee remains continuously disabled.

Maximum Monthly Benefit

This is the highest dollar amount an employee with a disability can receive on a monthly basis under the Long Term Disability plan.

Medical Necessity

Medical necessity is a term used to refer to a course of treatment seen as the most helpful for the specific health symptoms a member is experiencing.

Medicare

Title XVIII of the Social Security Act that provides payment for medical and health services to the population aged 65 and over regardless of income, as well as certain disabled persons and persons with ESRD.

Medicare Part A

Hospital insurance provided by Medicare that can help pay for inpatient hospital care, medically necessary inpatient care in a skilled nursing facility, home health care, hospice care and end-stage renal disease treatment.

Medicare Part B

Medicare-administered medical insurance that helps pay for certain medically necessary practitioner services, outpatient hospital services and supplies not covered by Part A hospital insurance of Medicare coverage. Doctors' services are covered under Part B even if they're provided to a member in an inpatient setting. Part B can also pay for some home health services when the beneficiary doesn't qualify for Part A.

Medicare Part D

A prescription drug benefit for Medicare-eligible seniors and disabled persons. It was established as part of the Medicare Prescription Drug, Improvement and Modernization Act (MMA) that President Bush signed into law on December 8, 2003. It goes into effect January 1, 2006.

Medigap

A term used to describe health benefits coverage that supplements Medicare coverage.

Member

An individual or dependent who is enrolled in and covered by a managed health care plan. Also called Enrollee or Beneficiary.

Mental Illness and Substance Abuse Limitations

When a disability is caused by a psychological/behavioral/emotional disorder, or by alcoholism or the non-medical use of drugs, benefits may be limited by the disability contract to a period of 12 or 24 months unless the employee is confined to a hospital.

Metals, classification of

The noble metal classification system has been adopted as a more precise method of reporting various alloys in dentistry commonly used in crowns, bridges and dentures. These alloys contain varying percentages of Gold, Palladium and/or Platinum. High noble contains more than 60% of Gold, Palladium, and/or Platinum (with at least 40% gold); noble contains more than 25% Gold, Palladium and/or Platinum; predominantly base contains less than 25% Gold, Palladium and/or Platinum.

Minimum Monthly Benefit

There is usually a minimum amount paid as a monthly benefit after reductions for "Other Income Benefits".

Molars

The broad, multicusped back teeth, used for grinding food are considered the largest teeth in the mouth. In adults there are a total of twelve molars (including the four wisdom teeth, or third molars), three on each side of the upper and lower jaws.

N

National Committee on Quality Assurance (NCQA)

An independent, nonprofit organization which assesses the quality of managed care plans, managed behavioral health care organizations and credentials verification organizations.

Network

A group of health care providers under contract with a managed care company within a specific geographic area.

Nitrous oxide

A controlled mixture of nitrogen and oxygen gases (N2O) that is inhaled by the patient in order to decrease sensitivity to pain. Also referred to as laughing gas.

Non-Participating Provider

A medical provider who has not contracted with a health plan.

Novocaine

A generic name for the many kinds of anesthetics used in the dental injection, such as Xylocaine, Lidocaine, or Novocaine. See local anesthetic.

O

Occlusal x-ray

An intraoral x-ray taken with the film held between the teeth in biting position.

Occlusal surface

The chewing surface of the back teeth.

Occlusion

Any contact between biting or chewing surfaces of upper and lower teeth.

Occupational Therapy

Treatment to restore a physically disabled person's ability to perform activities such as walking, eating, drinking, dressing, toileting, and bathing.

Onlay

A cast gold or porcelain filling that covers one or all of the tooth's cusps.

Open enrollment

A period when eligible persons can enroll in a health benefits plan.

Opt-out privilege

A general term used when some benefits are available for out-of-network covered services. Often coverage is less than the coverage available for in-network services, and the covered person has to pay for services up front and then file a claim for reimbursement. The details of such privileges, if they exist, will vary from plan to plan.

Oral surgery

The removal of teeth and the repair and treatment of other oral problems, such as tumors and fractures.

Orthodontics

A specialized branch of dentistry that corrects malocclusion and restores the teeth to proper alignment and function. There are several different types of appliances used in orthodontics, one of which is commonly referred to as braces.

Other Income Benefits

While disabled, an employee may be eligible for benefits from other sources. Benefits payable under the Long Term Disability plan may be reduced by other sources of income such as Social Security and workers' compensation.

Out-of-area benefits

Benefits the health plan provides to covered persons for covered services obtained outside of the network service area. The details of such benefits will vary from plan to plan.

Out-of-Network Provider

Any health care provider that does not belong to a specific payer's network. Members can use their benefits for out-of-network expenses, but miss out on in-network discounts.

Out-of-Pocket

Copayments, deductibles or fees paid by participants for health services or prescriptions.

Out-of-Pocket Maximum

The most a plan member will pay per year for covered health expenses before the plan pays 100% of covered health expenses for the rest of that year.

Outpatient care

Any health care service provided to a patient who is not admitted to a facility. Outpatient care may be provided in a doctor's office, clinic, the patient's home or hospital outpatient department.

Overbite

A condition in which the upper teeth excessively overlap the lower teeth when the jaw is closed. This condition can be corrected with orthodontics.

P

Paid Amount

The exact amount issued on a bank draft to the provider of service.

Palate

The hard and soft tissues forming the roof of the mouth.

Palliative

Treatment that relieves pain but is NOT curative.

Panorex

An extraoral full-mouth X-ray that records the teeth and the upper and lower jaws on one film.

Partial Day Treatment

A program offered by appropriately-licensed facilities that includes either a day or evening treatment program, usually for mental health or substance abuse.

Partial denture

A removable appliance used to replace one or more lost teeth.

Participant

A person who is eligible to receive health benefits under a health benefits plan. This term may refer to the employee, spouse or other dependents.

Participant ID

The unique identifier associated with a participant.

Participating Provider

A physician, hospital, pharmacy, laboratory or other appropriately licensed facility or provider of health care services or supplies that has entered into an agreement with a managed care entity to provide services or supplies to a patient enrolled in a health benefit plan.

PCP

See Primary Care Physician.

Pediatric dentistry

The specialized branch of dentistry that deals solely with treating children's dental disease. Also referred to as pedodontics.

Pended Claim

Claims that require additional information prior to completing the adjudication process due to a specific reason code.

Periapical

The area that surrounds the root tip of a tooth.

Pericoronitis

An inflammation of the gum tissue around the crown of a tooth, usually the third molar.

Periodontal

Relating to the tissue and bone that supports the tooth (from peri, meaning "around," and odont, "tooth").

Periodontal disease

The inflammation and infection of gums, ligaments, bone, and other tissues surrounding the teeth. Gingivitis and periodontitis are the two main forms of periodontal disease. Also called gum disease or pyorrhea.

Periodontal pocket

An abnormal deepening of the gingival crevice. It is caused when disease and infection destroy the ligament that attaches the gum to the tooth and the underlying bone.

Periodontal surgery

A surgical procedure involving the gums and jawbone.

Periodontics

The dental speciality that deals with and treats the gum tissue and bone that supports the teeth.

Periodontitis

Inflammation of the supporting structures of the tooth, including the gum, the periodontal ligament, and the jawbone.

Periradicular

The area which surrounds a portion of the root of the tooth.

Permanent teeth

The thirty-two adult teeth that replace the baby, or primary teeth. Also known as secondary teeth.

Physical therapy

Rehabilitation concerned with restoration of function and prevention of physical disability following disease, injury or loss of body part.

Pit

A recessed area found on the surface of a tooth, usually where the grooves of the tooth meet.

Plaque

A film of sticky material containing saliva, food particles, and bacteria that attaches to the tooth surface both above and below the gum line. When left on the tooth it can promote gum disease and tooth decay.

Point-of-Service (POS) plan

A health plan allowing the member to choose to receive a service from a participating or non-participating provider, with different benefits levels associated with the use of participating providers.

Policyholder

The group or individual to whom an insurance contract is issued.

Pontic

An artificial tooth used in a bridge to replace a missing tooth.

Pre-Admission Certification/Continued Stay Review (PAC/CSR)

The process through which the reviewer evaluates the attending physician's request for admission to an acute care hospital and length of stay. Medical necessity is determined using established criteria. If PAC/CSR is part of the health benefit plan, the admission or continued stay must be certified for full payment of a claim.

Precertification

The process of obtaining certification from the health plan for routine hospital stays or outpatient procedures. The process involves reviewing criteria for benefit coverage determination.

Pre-Disability Earnings

This is the amount of an employee's wages or salary that was in effect and covered by the plan on the day before the disability began.

Pre-Existing Condition

A health condition (other than a pregnancy) or medical problem that was diagnosed or treated before enrollment in a new health plan or insurance policy.

Pre-Existing Condition Limitations

When an employee has a physical or mental condition that existed prior to the effective date of his or her insurance coverage, it is considered a pre-existing condition. Most plans exclude or decrease disability benefits for an illness or injury for which an employee received medical treatment or consultation within a specified time period before becoming covered under the plan. The limitation generally expires after coverage has been in effect for a specified period of time.

Premolar

Another name for bicuspid.

Pre-Tax Account

An account in which contributions are subtracted from an employee's pay before withholding income tax and Social Security. This ultimately reduces the account-holder's tax liability, since taxes are based on income minus the account contribution.

Preferred Provider Organization (PPO) plan

A specific type of health plan which typicall has a national or large regional network of physicians. Plan members can visit physicians both in and out of the network, and can visit specialists without a referral. Members don't need to choose a primary care physician for coverage. An annual deductible is required, and an out-of-pocket maximum applies.

Prescription drug

A drug that has been approved by the Federal Food and Drug Administration which can only be dispensed according to physician's prescription order.

Preventive care

Medical and dental services aimed at early detection and intervention.

Preventive dentistry

Education and treatment devoted to and concerned with preventing the development of dental disease.

Preventive treatment

Any action taken by the patient, assisted by the dentist, hygienist, and the office staff that serves to prevent dental or other disease. Sealants, cleanings and space maintainers are examples of preventive treatment.

Primary care

The basic, comprehensive, routine level of health care typically provided by a person's general or family practitioner, internist or pediatrician.

Primary Care Physician (PCP)

A physician, usually a family or general practitioner, internist or pediatrician, who provides a broad range of routine medical services and refers patients to specialists, hospitals and other providers as necessary. Under some benefits plans, a referral by the primary care physician is required to obtain services from other providers. Each covered family member chooses his or her own PCP from the network's physicians.

Primary teeth

The first set of teeth that humans get, lasting until the permanent teeth come in. Also referred to as deciduous teeth or baby teeth.

Prior Authorization

See Precertification

Prophylaxis

The scaling and polishing procedure performed to remove calculus, plaque, and stains from the crowns of the teeth.

Prosthetic Devices

A device that replaces all or a part of the human body because a part of the body is permanently damaged, is absent or is malfunctioning.

Prosthodontics

The dental specialty dealing with the replacement of missing teeth and other oral structures.

Provider

A licensed health care facility, program, agency, physician or health professional that delivers health care services.

Provider Directory

Provider directories are listings of providers who have contracted with a managed care network to provide care to its participants.

Provider Network

A panel of providers contracted by a health plan to deliver medical services to the enrollees.

Pulp

The hollow chamber inside the crown of the tooth that contains its nerves and blood vessels.

Pulpectomy

Removal of the entire pulp from the canals in the root.

Pulpitis

An often painful inflammation of the dental pulp or nerve.

Pulpotomy

The removal of a portion of the tooth's pulp.

Q

Quadrant

The dental term for the division of the jaws into four parts, beginning at the midline of the arch and extending towards the last tooth in the back of the mouth. There are four quadrants in the mouth; each quadrant generally contains five to eight teeth.

R

Rebase

The process of refitting a denture by replacing the base material.

Receded gums

A condition characterized by the abnormal loss of gum tissue due to infection or bone loss.

Recurrent Disability

The recurrent disability provision is designed to protect an employee who tries to return to work but becomes disabled again from the same or a related cause. If this happens within a certain period of time, the employee will be considered disabled from the original disability, and will not be subject to a new elimination period. This encourages an employee to return to work without fear of losing benefits.

Referral

When a dental patient from one office is sent to another dentist, usually a specialist, for treatment or consultation.

Rehabilitation

Rehabilitation means the restoration of or improvement in an employee's health and ability to perform the functions of his or her job. It usually involves a program of clinical and vocational services with the goal of returning employees to a satisfying occupation if possible.

Reline

The process of resurfacing the tissue side of a denture with a base material.

Replantation

The return of a tooth to its socket.

"Residual" benefits

Residual benefits can help make up the difference in income if an employee is able to work, but limited in his/her responsibilities due to his/her disability.

Resorption

The breakdown and assimilation of the bone that supports the tooth, i.e., bone loss.

Restoration

Any material or devise used to replace lost tooth structure (filling, crown) or to replace a lost tooth or teeth (bridge, dentures, complete or partial).

Retainer

A removable dental appliance, usually used in orthodontics, that maintains space between teeth or holds teeth in a fixed position until the bone solidifies around them.

Retrograde filling

A method of sealing the root canal by preparing and filling it from the root tip, generally done at the completion of an apicoectomy.

Return to Work Provision

To encourage employees to return to work as soon as they become physically able, an additional incentive is usually provided for a certain period of time, and is called a return to work provision. Under this provision, the employee can receive up to 100 percent of pre-disability earnings based on a combination of disability benefits, other benefits, income and return-to-work earnings.

Root

The part of the tooth below the crown, normally encased in the jawbone. It is made up of dentin, includes the root canal, and is covered by cementum.

Root canal

The hollow part of the tooth's root. It runs from the tip of the root into the pulp.

Root canal therapy

The process of treating disease or inflammation of the pulp or root canal. This involves removing the pulp and root's nerve(s) and filling the canal(s) with an appropriate material to permanently seal it.

Root planing

The process of scaling and planing exposed root surfaces to remove all calculus, plaque, and infected tissue.

S

Scaling

A procedure used to remove plaque, calculus and stains from the teeth.

Sealant

A composite material used to seal the decay-prone pits, fissures, and grooves of children's teeth to prevent decay.

Service area

The geographical area covered by a network of health care providers.

Six-year molar

The first permanent tooth to erupt, usually between the ages of five and six.

Skilled Nursing Facility (SNF)

A licensed facility that provides nursing care and related services for patients who do not require hospitalization in an acute care setting.

Socket

The hole in the jawbone into which the tooth fits.

Space maintainer

A dental appliance that fills the space of a lost tooth or teeth and prevents the other teeth from moving into the space. Used especially in orthodontic and pediatric treatment.

Specialists

Providers whose practices are limited to treating a specific disease (e.g., oncologists), specific parts of the body (e.g., ear, nose and throat), a specific age group (e.g., pediatrician), or specific procedures (e.g., oral surgery).

Speech Therapy

Treatment to correct a speech impairment that resulted from birth or from disease, injury or prior medical treatment.

Staff Model HMO

An HMO where doctors are employed by the health plan and provide care at a health care center facility.

Stainless steel crown

A pre-made metal crown, shaped like a tooth, that is used to temporarily cover a seriously decayed or broken down tooth. Used most often on children's teeth.

Status change

A lifestyle event that may cause a person to modify their health benefits coverage category. Examples include, but are not limited to, the birth of a child, divorce or marriage.

Subgingival scaling

The removal of calculus and plaque found on the tooth below the gum line.

Submission Date

The date the claim was submitted and/or received by a payer.

Supra gingival scaling

The removal of calculus and plaque found on the tooth above the gum line.

Systemic

Relating to the whole body.

T

Tartar

See calculus.

Temporomandibular joint (TMJ)

The connecting hinge mechanism between the upper jaw and the base of the skull.

Temporomandibular joint (TMJ) syndrome

The problems associated with TMJ, usually involving pain or discomfort in the joints and ligaments that attach the lower jaw to the skull or in the muscles used for chewing.

Third molar

The last of the three molar teeth, also called wisdom teeth. There are four third molars, two in the lower jaw and two in the upper jaw, one on each side. Some people are born without third molars.

Torus

A bony elevation or protuberance of normal bone. Usually seen on the upper palate behind the front teeth or under the tongue inside the lower jaw.

Treatment plan

A list of the work the dentist proposes to perform on a dental patient based on the results of the dentist's X rays, examination, and diagnosis. Often more than one treatment plan is presented.

U

Urgent Care

When prompt medical attention is needed in a non-emergency situation, that's called "urgent" care. Examples of urgent care needs include ear infections, sprains, high fevers, vomiting and urinary tract infections. Urgent situations are not considered to be emergencies.

Usual, Customary or Reasonable (UCR)

The amount reimbursed to providers based on the prevailing fees in a specific area.

V

Veneer

An artificial filling material, usually plastic, composite, or porcelain, that is used to provide an aesthetic covering over the visible surface of a tooth. Most often used on front teeth.

W

Waiting Period

In order to become eligible for coverage under the policy, an employee must satisfy a certain number of continuous days of service as an active, full-time employee. This is known as the waiting period. In addition, a waiting period can also be the time period between when a disability occurs and when payments from the disability insurance policy begin.

Waiver of Premium

When an individual becomes disabled and eligible for benefits, no further disability premium payments are required as long as benefits are being paid out.

Wisdom teeth

See third molar.

X

no x items

Y

no y items

Z

no z items