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Glossary

The definitions in this glossary are based on current usage in the dental benefit industry. Some terms defy rigid definition and can be described only as to use and meaning. Also, certain terms are defined in state insurance codes, which vary from state to state. As dental benefit coverage continues to grow, further revisions may well be necessary.

A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z

 

A

Administrator: One who manages or directs a dental benefit program on behalf of the program's sponsor, also known as a third-party administrator (TPA), dental benefit organization, carrier and /or insurer.

Administrative Costs: Overhead expenses incurred in the operation of a dental benefit program, exclusive 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: The occurrence within a dental benefit program when those eligible for the program choose to enroll on the basis of their need, thereby utilizing more services than the average expected for all eligible.

Allowable Charge: The maximum dollar amount determined by the plan on which benefit payment is based for each dental procedure.

Alternate Benefit: A provision in a dental benefit contract that allows the third-party payer to determine the benefit based on another professionally acceptable procedure that is generally less expensive than the one provided or proposed.

Alternative Benefit Plan: A plan, other than a traditional 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 fee-for-service manner. An example of alternative delivery systems includes, but is not limited to, a company-owned industrial clinic.

Assignment of Benefits: A procedure whereby a covered person authorizes the administrator of the program to forward payment for a covered procedure directly to the treating dentist.

Attending Dentist's Statement:
The claim form developed by the American Dental Association. Also see Claim Form.

Audit: A post-treatment record review or clinical examination to verify claim information or the quality or appropriateness of treatment reported on claims.

 

B

Balance Billing: A process of billing a patient for the difference between the actual charge and the amount received by the dentist from a dental benefit program.

Beneficiary: A person who receives benefits under a dental benefit contract. Also known as Eligible Individual and Enrollee. Also see Covered Person, Insured, Member or Subscriber.

Benefit: 1.) The amount payable by a third party toward the cost of various covered dental services. 2.) The dental service or procedure covered by the plan.

Benefit Booklet: A booklet or pamphlet for the contract holder that outlines the benefits and related provisions of the dental benefit program. Also known as summary plan description.

Benefit Plan Summary: The benefit booklet required by ERISA to be distributed to employees.

Bill Payer: See Direct Reimbursement Plan.

Birthday Rule: A method to determine the primary payer of benefits for dependent children when both parents have dental benefits programs. The program of the parent whose birthdate falls first in a calendar year is considered the primary.

 

C

Cafeteria Plan: Employee benefit plan in which employees select their 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: 1.) An alternative reimbursement mechanism to the fee-for-service method of providing a contracting dentist with monetary compensation for services rendered. The contracting dentist is compensated on a periodic (usually monthly) fixed rate per capita (patient or family) in return for treating the comprehensive needs of the patient(s). The dentist is compensated whether or not services are provided. The contracting dentist assumes the financial risk, since the payment received by the dentist may not be sufficient to cover the cost of the treatment. 2.) Often refers to a type of alternative dental practice modes. Also see Closed Panel.

Carrier: See Third Party.

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 who has a dental benefit program as a result of being employed, retired or widowed. Also known as subscriber. 2.) The "sponsor" or active duty military personnel whose dependents are covered by the Civilian Health and Medical Program of the Uniformed Services.

Claim: 1.) A demand for payment under a dental benefit contract. 2.) A statement listing services rendered, the dates of services and itemized costs. Usually includes a certification signed by the beneficiary and dentist that services have been rendered. The completed form serves as the basis for payment of benefits.

Claimant: Person who files 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. Also see Attending Dentist's Statement.

Closed Panel: Dental practice mode whereby patients who are eligible for dental services (in either a private or public program) can receive services only at specified facilities by a limited number of participating dentists. If the services are provided in a group practice facility and are prepaid by a third party, the practice is more precisely termed "prepaid group practice." Contracting dentists may be compensated on a salary, percentage of gross, fixed schedule fee or combination basis, or they may assume financial risk of providing care within the premium income of the plan, such as with a capitation mechanism.

Coinsurance: See Copayment.

Consolidated Omnibus Budget Reconciliation Act (COBRA): Federal legislation relative to continuation of health benefits for all types of employee benefit plans that are provided by the employer. The most significant aspect is the requirement that employees and/or their dependents that become ineligible for coverage may purchase continued coverage for an additional 18 months (30 months for dependents in the event of the employee's death).

Contract: A legally enforceable agreement between two or more individuals or entities that 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. 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 Organization (CDO): A practitioner, institution or a combination of both that enters into an agreement with a purchaser of group benefits to provide services in manner that is less expensive (for the purchaser, the members of the group, or both) than a traditional treatment delivery arrangement. In return, the purchaser agrees to publicize this agreement to the group members. Also known as Preferred Provider Organization (PPO).

Contract Fee Schedule Plan: A dental benefit plan in which participating dentists agree to accept a list of specific fees as the payment in full 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.

Contract Year: The period of time, usually but not necessarily 12 months, for which a contract is written.

Contributory Program: Dental benefit program in which the enrollee shares in the monthly premium of the program with the program sponsor (usually the employer). Generally done through payroll deduction.

Coordination of Benefits (COB):
Method of integrating benefits payable under more than one plan such that benefits from all sources should not exceed 100 percent of the total charges.

Copayment: 1.) A provision of a dental benefit program by which the beneficiary shares in the cost of covered services, generally on a percentage basis. However, some programs may have a stated dollar amount. A typical coinsurance arrangement is one in which the third party pays 809 percent of the allowed benefit of the covered dental service and the patient 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. 2.) Payment by a beneficiary of a flat dollar amount per unit of service. Also known as Surcharge.

Corporate Dentistry: Refers to company-owned and operated closed panel dental care facility or industrial clinic, provides services to employees and some-times dependents. Also see Closed Panel.

Cost Containment: Features of a dental benefit program or of the administration of the program designed to reduce or eliminate certain charges to the plan.

Cost Sharing: Responsibility for partial payment by the patient for services rendered. Also see Copayment, Deductible and Surcharge.

Council on Dental Care Programs: Agency designated by a dental society, e.g., American Dental Association, constituent or component society, or national dental organization, charged with 1.) formulating and recommending policies relating to the planning, administration and financing of dental care programs; 2.) studying, evaluating and disseminating information, the planning, administration and financing of dental care programs; 3.) assisting constituent societies and other agencies in developing programs for planning, administration and financing of dental care programs; and 4.) providing assistance, guidance and support to constituent and component societies in the development and management of professional review systems.

Coverage: Benefits available to an individual under a dental benefit plan.

Covered Charges: Charges for services rendered or supplies furnished by a dentist that qualify as covered services and are paid for in whole or in part by the dental benefit program. May be subject to deductibles, copayments, coinsurance or table of allowances, as specified by the terms of the contract.

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.

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.

 

D

Deductible: The amount of dental expense for which the beneficiary is responsible before the benefits of the contract go into effect. Deductible may be an annual or one-time charge, and may vary in amount from program to program. Also see Family Deductible.

Dental Benefit Organization: Any organization offering a dental benefit plan. Also known as a 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 maximum to control the cost of the program to the purchaser. May also refer to a direct reimbursement program.

Dental Benefit Program:
The specified dental benefit plan being offered to enrollees by the sponsor. Also known as dental care program.

Dental Care Program: See Dental Benefit Program.

Dental Insurance: A policy that insures against the expense of treatment and care of dental disease and accident to teeth.

Dental Prepayment: A method of financing the cost of dental services in advance of their receipt.

Dental Service Corporation: Legally constituted not-for-profit organization as defined by state statute, which provides benefits on a service benefit basis; in most states called a "Delta Dental Plan."

Dependents: Generally spouse and children of contract holder, as defined by the terms of the dental benefit contract. In some contracts, other family members may also be considered dependents.

Direct Billing: A process whereby the dentist bills a patient directly for the amount the dentist determines to be appropriate for services provided.

Direct Reimbursement Plan: The implementation of a Direct Reimbursement Program results in a plan which reimburses beneficiaries according to their dollars spent on dental care. For example, a Direct Reimbursement Dental Plan may reimburse at the following rate:

  • 100 percent of the first $100 for dental expenses
  • 80 percent of the next $500
  • 50 percent of the next $1,000

for a resulting $1,000 annual maximum benefit.

Direct Reimbursement Program: A program designed to reimburse beneficiaries an amount based on dollars spent on dental care, not on service received, and allow the beneficiaries to go to the dentist of their choice.

DRG (Diagnosis-Related Groups): A system of classifying hospital patients on the basis of diagnosis, consisting of distinct groupings. The system was originally developed by the Medicare program through a Federal initiative for the primary purpose of cost containment. 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: A benefit offering by a program sponsor in which eligible individuals are given the option to enroll in either an alternative dental benefit program or a traditional dental benefit program.

 

E

Eligibility Date: The date an individual and/or dependents become eligible for benefits under a dental benefits contract. Often referred to as effective date.

Eligible Individual: See Beneficiary.

Enrollee: 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.

Exceptions: See Exclusions.

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

Exclusive Provider Arrangement: 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 benefits contract expires. 2.) The date an individual ceases to be eligible for benefits.

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.

 

F

Family Deductible: A deductible that is satisfied by combined expenses of all covered family members. For example, a program with a $25 deductible may limit its application to a maximum of three deductibles, or $75 for the family, regardless of the number of family members. Also see Deductible.

Fee-for-Service: The traditional method of billing by dentists in private practice, whereby the dentist charges a specific fee for each dental service performed.

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. Also see Cafeteria Plan, Flexible Spending Account.

Flexible Spending Account: Employee reimbursement account funded with employee designated salary reductions. Funds are reimbursed to employees 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 or regulations. 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.

 

G

Gate Keeper System: A managed care concept used by some alternative benefit plans, in which enrollees elect 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 services.

 

H

Health Maintenance Organization (HMO): 1.) Traditional: A legal entity that has met the requirements of the HMO Act of 1973 by providing basic and supplemental health services to an enrolled population in exchange for prenegotiated and fixed periodic payments. 2.) Current: An organized system of health care delivery that provides comprehensive care to enrollees through designated providers. Enrollees are generally assessed a monthly payment for health care service and may be required to remain in the program for a specified amount of time.

Hold Harmless Clause: A contract provision in which the 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 individual dentists often contain a promise by the dentist to reimburse the dental benefit organization for an6y liability the organization incurred 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 organization 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.

 

I

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. For example, a 70 percent-30 percent copayment program in the first year of coverage may become an 80 percent-20 percent program in the second year if the subscriber visits the dentist in the first year as stipulated in the program. Most frequently, there is a corresponding percentage reduction in the program's copayment level if the covered individual fails to visit the dentist in a given year (but never below the initial copayment level).

Indemnification Schedule: See Table of Allowances.

Indemnity Plan: A dental plan that provides payment by a third-party payer of a net amount, or percentage thereof, 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 an individual participating dentist 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. (Trans. 1976:866)

In-office Audit: See Audit.

Insurer: See Third Party.

Insured: Person covered by the program. Also see Beneficiary.

 

L

Liability: An obligation for a specified amount or action.

Limitations: 1.) Restrictive conditions stated in a dental benefit contract, such as age, length of time covered and writing periods, which affect an individual's or group's coverage. 2.) The exclusion of certain benefits or services. 3.) The extent or conditions under which certain services are provided. Also see Exclusions.

 

M

Managed Care: Any form of health plan that initiates selective contracting to channel patients to a limited number of providers and requires utilization review to control unnecessary use of health services.

Maximum Allowance: The maximum dollar amount a dental program will pay toward the cost of 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 payment in full for one or more covered services.

Medicaid: A federal assistance program established as Title XIX under Social Security Amendments 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.

Medicare: A federal insurance program enacted in 1965 as Title XVIII to the Social Security Amendments, which provides certain in-patient hospital services and physician services for all people 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.

 

N

Necessary Treatment: An essential 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 the sponsor pays the entire monthly premium for the program.

Nonduplication of Benefits: A dental benefit contract provision relieving the third-party payer of liability for cost of services 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 percent of the charges.

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. Also known as "non-par" dentist.

Not-for-Profit Third Parties: Service corporations or 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.

 

O

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.

 

P

Participating Dentist: Any dentist who has a contractual agreement with a dental benefit organization to render care to eligible people.

Payer: In health care, generally refers to entities, other than the patient, that finance or reimburse for 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; and /or of disputes regarding fees/ of cases submitted by carriers or initiated by patients; of 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 care 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 that 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 percent and the upper 10 percent, or that fee level at which 90 percent of dentists charge that amount or less and 10 percent charge more.

Post-treatment Review: See Audit.

Preauthorization: Statement by a third-party payer indicating that proposed treatment will be covered under the terms of the dental benefit contract. Also see Precertification, Predetermination.

Precertification: Confirmation by a third-party payer of a patient's eligibility for coverage under a dental benefit program. Also see Preauthorization, Predetermination.

Predetermination: An administrative procedure where a dentist submits his treatment plan to the third party before treatment is begun. The third party usually returns the treatment plan indicating available benefits.

Pre-existing Condition: Oral health condition of an enrollee that existed before his/her enrollment in a dental program.

Preferred Provider Organization (PPO):
See Contract Dentist Organization.

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 specified time and level of benefits.

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.

Prime: The dental benefit program in which employees who are offered a dual choice option are automatically enrolled, unless they choose another program.

Prior Authorization: See Preauthorization.

Professional Standards Review Organization (PSRO): Archaic. See Peer Review Organization.

Proof of Loss: Verification of services rendered (expenses incurred) by the submission of claim forms, radiographs, study models and/or other diagnostic material.

Purchaser: Program sponsor, often the employer or union, that contracts with the dental benefit organization to provide dental benefits to an enrolled population.

 

Q

Quality Assurance: The assessment or measurement of the quality of care and the implementation of any necessary changes to either maintain or improve the quality of care rendered.

 

R

Reasonable and Customary (R&C) Plan: A dental benefit plan that determines benefits based only on "Reasonable and Customary" fee criteria. Also see Customary Fee, 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, 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 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 story 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 mode of practice, not a dental benefits plan model.

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.

 

S

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.

Screening: See Audit.

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 for an insurance carrier.

Service Benefit: A type of dental benefit contract between a beneficiary and a third-party payer whereby the beneficiary is guaranteed not out-of-pocket expenses for covered services beyond any agreed on cost-sharing stipulated in the contract.

Service Benefit Plan: A prepaid dental plan that incorporates the service benefit concept. Also known as a service plan.

Stop-Loss: A general term referring to the 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 Beneficiary, Certificate Holder.

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 from third-party payer(s).

 

T

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.

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.

Termination Date: See Expiration Date.

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 or Underwriter.

Third-Party Administrator: 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 (AS) contracts.

 

U

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: 1.) The extent to which the members of a covered group use a program over a state period of time; specifically measured as percentage determined by dividing the number of covered individuals who submitted on 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 or time.

Utilization Review: Statistical analysis of utilization data.

 

W

Waiting Period: The period between employment and enrollment in a dental program and the date when a covered person becomes eligible for benefits.

 

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