The following is intended to provide a quick reference for terms relating to Direct Reimbursement promotion. These definitions have been compiled by staff in the Council of Dental Benefit Programs and should not be understood to represent official ADA/MDA policy.

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 (1987 House Reference Committee: 1502). Also see 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. The deductible may be an annual or one-time charge, and may vary from program to program.

Direct Reimbursement: A self-funded program that reimburses an individual based on a percentage of dollars spent for dental care and allows patients to seek treatment from the dentists of their choice.

Exclusions: Dental services not covered under a dental benefit program.

Fee-For-Service: A method of paying practitioners on a service-by-service salaried or capitated basis.

Flexible Spending Account (FSA): Employee reimbursement account primarily funded with employee designated salary reductions. Funds are reimbursed to employee for health care (medical and/or dental), dependant care, and/or legal expenses, and are considered a non-taxable benefit.

Managed Care: This refers to a cost containment system that directs the utilization of health care by a.) restricting the type, level and frequency of treatment; b.) limiting the access to care; and c.) controlling the level of reimbursement for services.

PINSERV: The acronym for the ADA's Purchaser Information Service, which provides informational materials to members and employers regarding dental benefits plans options.

Pre-Authorization/Pre-Determination: These are administrative procedures that may require a dentist to submit a treatment plan to a third-party payer for approval before treatment is begun.

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, by any medical or dental complications or unusual circumstances. It therefore may differ from the dentist's "usual" fee or the benefit administrator's "customary" fee. (1987 House Reference Committee: 1502) Also see Customary Fee, Usual 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.

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 third party administrator. Self-funded programs often have stop loss insurance in place to cover abnormal risks.

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.

Usual, Customary and Reasonable (UCR) Plan: A dental benefit plan that determines benefits based on "Usual, Customary and Reasonable" fee criteria. Also see Usual Fee, Customary Fee and Reasonable Fee.

Usual Fee: The fee that an individual dentist most frequently charges for a given dental service. (1987 House Reference Committee: 1502) Also see Customary Fee and Reasonable Fee.

Utilization: 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.