Dental Insurance Terminology
Allowable Charges- The maximum dollar amount on which benefit payment is based for each dental procedure.
Alternate Benefit- If Ameritas determines that a less expensive alternate procedure, service or course of treatment can be performed in place of the proposed treatment to correct a dental condition; and the alternate treatment will produce a professionally satisfactory result; then the maximum we will allow will be the charge for the less expensive treatment.
Basic Services- Dental procedures concerned with the repair or restoration of individual teeth due to decay, trauma or impaired function. Basic services may include oral surgery, endodontics (root canals), fillings, and periodontics (tissue/bone treatment). See your policy or brochure for full details on what your PrimeStar plan includes.
Benefit- The amount payable by a third party toward the cost of various covered dental services or procedure covered by the plan.
Benefit Year- Benefit coverage period, 12 months long, which runs one (1) year from the effective date of the policy.
Covered Person- Individual who is eligible for benefits under a dental benefit program.
Covered Services- The service(s) for which payment is provided under the terms of the dental benefit contract.
Deductible- Predetermined amount within a given time period that a member is required to pay toward covered services before the insurance company will make any payment. For example, a member might have to pay for the first $25 of covered services in a calendar year before the insurance company starts to pay.
Dependents- Generally spouse and children of covered individual, as defined by terms of the dental benefit contract.
Enrollee- Person who receives benefits under a dental benefit contract (also known as: covered person, insured, member).
Exclusions- Dental services not covered under a dental benefit program. See your policy or brochure for full details on what your PrimeStar plan includes.
Expiration Date- 1) date on which the dental benefit contract expires. 2) date an individual ceases to be eligible for benefits. (also known as termination date)
Explanation of Benefits (EOB)- The EOB details how the claim was processed and indicates the portion of the claim already paid to the dentist and the portion of the claim that is the responsibility of the insured (if applicable). The EOB is not a bill.
Family Deductible- Deductible which may be satisfied by the combined expense of all covered family members.
Fee-for-service- Method of paying practitioners on a service-by-service rather than a "salaried basis".
Fee Schedule- List of the charges established or agreed to by a dentist for specific dental services.
HIPAA- Health Insurance Portability and Accountability Act of 1996. The law's primary intent is to provide better access to health insurance, limit fraud and abuse, and reduce administrative costs through simplification.
Indemnity Plan- Ameritas offers indemnity dental insurance plans. In this type of dental insurance plan, you have the option to visit any dentist or dental care professional you wish. You do not need to select your dentist from a list of network providers or approved providers to qualify for benefits and coverage. This provides more flexibility to you and is ideal for those who reside in an area with no network providers. If you do choose to use one of the in-network dentists, you will see greater benefits and savings. This is an option available for you to use at any time.
Insurer- Organization that bears the financial risk for the cost of defined categories or services for a defined group of beneficiaries. With all PrimeStar plans, Ameritas is the insurer.
Limitations- Restrictive conditions stated in a dental benefit contract, such as age, length of time covered, and waiting periods, which affect an individual's coverage. The contract may also exclude certain benefits or services, or it may limit the extent or conditions under which certain services are provided. See your policy or brochure for full details on what your PrimeStar plan includes.
MAC PPO Plan- Ameritas' PrimeStar dental plans give you the freedom to use any dentist with the option of utilizing a Ameritas dental network provider for greater savings. When you utilize one of our PPO providers from the Ameritas dental network, your out-of-pocket costs will be lower because of the agreed upon negotiated fee for services. You are responsible for any coinsurance and the required deductible. It is important to note that if you receive care from a non-Ameritas provider, your out-of-pocket costs will be based on what the provider charges.
Major Services- Dental procedures concerned with the restoration of teeth by cast restorations such as inlays, onlays, crowns, or veneers. Major services may also include endodontics (root canals) or periodontics (tissue/bone treatment). See your policy or brochure for full details on what your PrimeStar plan includes.
Maximum Benefit Amount- Maximum dollar amount a program will pay toward the cost of dental care incurred by an individual or family in a specific time period.
Maximum Fee Schedule- Compensation agreement in which a participating dentist agrees to accept a prescribed sum as the total fee for one or more covered services (also known as: maximum allowable reimbursement).
Noncontributory Program- A method of payment for group coverage in which the entire monthly premium for the program is paid by the sponsor.
Options- Additional benefits, like an increased Maximum Benefit Amount or vision rider that you can add to your plan for an additional cost.
Point-of-Service- Arrangements in which patients with a managed care dental plan have the option of seeking treatment from an "out-of-network" provider. The reimbursement for the patient is usually based on a lower table of allowances with significantly reduced benefits than if the patient had selected an "in-network" provider.
Policy Holder- An individual that has entered into an insurance contract.
PPO Plan- Ameritas' PrimeStar dental plans give you the freedom to use any dentist with the option of utilizing a Ameritas dental network provider for greater savings. When you utilize one of our PPO providers from the Ameritas dental network, your out-of-pocket costs will be lower because of the agreed upon negotiated fee for services. You are responsible for any coinsurance and the required deductible. It is important to note that if you choose to go to a non-Ameritas provider, your out-of-pocket costs will be based on the Usual & Customary charge.
Predetermination of Benefits- If the treatment plan will exceed the amount shown in the Coverage Schedule, Ameritas requests prior review. We must be given the treatment plan consisting of a description of the planned treatment with estimated charges and diagnostic information. We will determine eligible expenses and state how much we will pay for the treatment. Our determination may suggest an alternate, less expensive treatment plan if it will produce professionally satisfactory results. If you do not request a prior review of a treatment plan, we will pay for the least expensive method of treatment regardless of the method actually used.
Pre-existing Conditions- Oral health condition of an enrollee which existed before his/her enrollment in a dental program.
Premium- Amount charged for coverage of a level of benefits for a specified time.
Preventive Services- Dental procedures concerned with the prevention of dental diseases by protective and educational measures. May include examination, cleanings and fluoride. See your policy or brochure for full details on what your PrimeStar plan includes.
Provider- Unique individual dentist (preferred providers, general dentists, specialty providers, practicing providers).
Usual and Customary- The usual and customary charges for the area where such expenses are incurred.
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.
Waiting Period- This is the time a member must wait from the effective date of coverage for certain procedures to be covered. These are different for each plan. We offer plans with no waiting periods.
Dental Terms Abscess-
Acute or chronic, localized inflammation associated with tissue destruction.
Abutment- Tooth or root that retains or supports a bridge, fixed or removable prosthesis.
Air Abrasion- A device that uses tiny particles of aluminum oxide blasted in a stream of air at the tooth to remove the decayed debris and ruined enamel of cavities. This procedure usually eliminates the need for anesthesia, though it is not usable for all procedures where a drill has normally been used.
Amalgam- An alloy used in direct dental restorations.
Anesthesia- Drugs and procedures that relieve the sensation of pain. Various types include general anesthesia, IV sedation, needle-less anesthesia and local anesthesia.
Apicoectomy- Surgery to the root section of the tooth through the side of the gums where the root is severed at the base of the tooth and then the tooth is filled. Usually this is done when a root canal has failed to eliminate pain or infection, and is usually performed by an endodontist.
Attrition- The normal wearing down of the surface of a tooth from chewing.
Autoclave- A device that has a chamber where instruments are placed and steam under pressure is injected in order to complete sterilization. OSHA (Occupational Safety & Health Administration) standards require all dental offices have sterilization procedures for instruments that include the use of an autoclave.
Baby Bottle Tooth Decay- Severe decay in baby teeth due to sleeping with a bottle of milk or juice. The drink's natural sugars combine with bacteria in the mouth to produce acid that decays teeth.
Bite- The way the mouth closes, or the way in which the upper and lower teeth meet.
Bonding- A composite resin is applied to a tooth to change its shape and/or color. Bonding also refers to how a filling, orthodontic appliance or some fixed partial dentures are attached to teeth.
Bridge- Prosthetic (false) tooth or row of teeth that spans between two natural teeth to replace missing or lost teeth. An alternative to a bridge would be a dental implant.
Braces- Devices used by orthodontists to gradually reposition teeth. There are several varieties of braces, including invisible, plastic and metal appliances. They can also be placed on the interior or exterior of the teeth.
Bruxism- Involuntary clenching or grinding of the teeth during the day or while asleep.
Calculus- Hard deposit of mineralized material, or calcified plaque, that adheres to teeth or crowns. (also known as tarter)
Caries- A common term for tooth decay.
Cap- A porcelain or gold cover for a decayed, damaged, brittle, or discolored tooth. (Also known as a crown.)
Cavity- A decay lesion or a hole in the tooth caused by tooth decay.
Cementum- A thin layer of hard connective tissue that covers the root of the tooth.
Composite Filling- A tooth-colored filling made of a polymer material that looks like a natural tooth. Used instead of metal amalgam. Alternatives are gold or porecelain inlays.
Crown- The artificial covering of a tooth with metal, porcelain or porcelain fused to metal that covers teeth that are weakened by decay or severely damaged or chipped.
Cuspids- The large single-cusped (pointed) teeth at the corners of the mouth, located between the incisors and bicuspids. (Also known as canine teeth.)
Cusps- The raised round parts on the chewing surface of the teeth.
Deciduous Teeth- Baby teeth or primary teeth include a set of twenty teeth that are usually replaced by permanent teeth.
Dental Floss- A waxed or unwaxed piece of nylon string that is inserted between the teeth and moved in an up/down fashion for the removal of plaque or other food deposits. Essential care for healthy teeth and gums, at least once a day.
Diastema- The space between teeth, most often referring to the top two center teeth.
Digital Radiography- The use of computer imaging rather than traditional x-ray film to create and store images of teeth.
Electronic Anesthesia- Sends electrical impulses blocking pain signals to the brain through electrodes placed near the teeth. Used as an alternative to injected anesthesia, and not effective for all patients and procedures. Often referred to as H-Wave.
Enamel- The hard calcified tissue covering over the outside of the tooth. It is the hardest substance in the body.
Endodontics- A dental specialty concerned with treatment of the root and nerve of the tooth.
Endodontist- A specialist in the dental field who treats injuries, diseases and infections of the tooth pulp (nerve tissue).
Extraction- The removal of a tooth that is severely decayed, broken, loose, or causing crowding.
Filling- Restoring lost tooth structure with amalgam, metal, porcelain, or composite resin. Used as part of the treatment of cavities.
Fluoride- A chemical compound that prevents cavities and makes the tooth surface stronger so that teeth are able to resist decay.
General Anesthesia- A controlled state of unconsciousness or deep sleep, accompanied by a partial or complete loss of pain sensation, as well as protective reflexes, and including a loss of the ability to independently maintain a breathing airway and respond purposefully to verbal or physical stimulation. Must be administered by a licensed anesthesiologist.
Gingivitis- inflammation of the gums surrounding the teeth caused by a buildup of plaque or food particles.
Halimeter- An instrument used in the diagnosis and treatment of chronic halitosis.
Halitosis- A term for bad breath. Many dentists offer treatment programs for halitosis that are more effective than over-the-counter remedies.
Heat Sterilization- A procedure that involves a chamber into which instruments are placed and which raises the temperature for a period of time to kill all microorganisms. OSHA (Occupational Safety & Health Administration) standards require all dentists to use heat sterilization for dental instruments.
H-Wave- A device for electronic anesthesia that sends electrical impulses blocking pain signals to the brain through electrodes placed near the teeth. Used as an alternative to injected anesthesia, and not effective for all patients and procedures.
Hygienist- A dental professional qualified to clean and scale teeth. They also educate patients on proper dental care.
Imaging- A photograph of teeth stored in a computer and then displayed on a television monitor. The dentist is able to show you an image of your smile and modify that image to show how your smile would look with new, repaired, or whitened teeth. (Also called video imaging.)
Impacted Tooth- A tooth that fails to erupt properly and remains fully or partially embedded and covered over by bone or gum tissue. This most often occurs with wisdom teeth. If it’s not removed, impacted teeth can cause pain, headaches, infection and malocclusion. Most often treated by an oral surgeon.
Implant- A fixed replacement for a missing tooth. The procedure involves the implanting of a metal shaft, usually titanium, implanted in the jawbone. A prosthetic (artificial) tooth is then affixed to this shaft, providing a strong permanent replacement for a lost tooth. Implants also prevent the gradual loss of bone material in the jaw that occurs over time with the use of dentures.
Impressions- An imprint of hard teeth or soft issues used to create a cast or positive model.
Incisors- The four upper or lower single cuspid front teeth designed for incising (cutting) food.
I.V. Sedation- Anesthesia administered intravenously, used for people who want to be asleep during dental procedures. It is sometimes described as a light anesthesia. Special licensing is required for a dentist to perform this type of sedation in their office. Other types of anesthesia include general anesthesia and local anesthesia.
Lasers- Dental lasers are a family of instruments, some used for oral surgery, some to cure (harden) restorative tooth materials and enhance tooth bleaching, and others to remove tooth structure to eliminate disease. Lasers are also sometimes used to treat gingivitis (gum disease). New lasers are constantly being developed and refined, and can sometimes eliminate the need for drilling.
Local Anesthesia- Relieves the sensation of pain in a localized area. Done topically or by injection. Other forms of pain management include H-wave, DentiPatch, I.V. sedation, general anesthesia and nitrous oxide.
Malocclusion- The improper alignment of biting or chewing surfaces of the upper and lower teeth.
Molars- The back teeth that used for grinding food before swallowing.
Mouthguard- A removable appliance used to protect teeth from injury during athletic activities. It is most effective when created by a dentist who takes exact impressions of the user's teeth to make the guard.
Needleless Anesthesia- An anesthesia administered without the use of injections, such as the H-wave and DentiPatch.
Nightguard- A removable acrylic appliance used to minimize the effects of grinding the teeth (bruxism) or joint problems (TMD), usually worn at night. The appliance is created by a dental laboratory using exact impressions of the patient's teeth taken by a dentist.
Nitrous Oxide- Colorless, sweet-tasting gas with a pleasing smell when inhaled (also called laughing gas), used to help patients relax during treatment. While not technically a form of anesthesia, the distraction and relaxation of the patient usually helps to reduce the discomfort of the procedure.
Onlay- An inlay made of gold or porcelain that is extended to cover the cusps for protection of the tooth, leaving more natural tooth than a crown.
Oral Sedation- Any substance taken orally to reduce anxiety and relax the patient. This is often used in conjunction with some form of anesthesia during dental procedures.
Oral and Maxillofacial Surgeon- A specialist who deals with the diagnosis and surgical treatment of diseases, injuries, and deformities of the mouth and supporting structures. Often simply called an oral surgeon.
Oral Surgery- The surgery of the mouth including removal of teeth, particularly wisdom teeth.
Orthodontics- A dental specialty concerned with straightening or moving misaligned teeth or jaws. An orthodontist is a dental specialist in this field.
Orthodontist- A dental specialist who corrects irregularities of the teeth primarily through the use of braces or a retainer.
Palate- The general term that refers to the roof of the mouth.
Panoramic Radiograph- A single large x-ray of the jaws taken by a machine that rotates around the head.
Partial Denture- A removable appliance (prosthesis) that replaces some of the teeth in either the upper or lower jaw, as opposed to a full denture, which replaces all the upper or lower teeth.
Pediatric Dentistry- A dental specialty focusing on treatment of children's teeth.
Pedodontics- A dental specialty concerned with treatment of children. A pedodontist is a dental specialist in this field (also known as a pediatric dentist).
Periodontitis- Inflammation and loss of connective tissue of the supporting or surrounding structure of the teeth (also known as gum disease).
Plaque- A bacteria-containing substance that collects on the surface of teeth. Plaque can cause decay and gum irritation when it is not removed by daily brushing and flossing.
Prophy Jet- Air polishing for stain removal.
Prophylaxis- A professional cleaning to remove plaque, calculus (mineralized plaque) and stains to help prevent dental disease (Also known as a prophy).
Prosthodontics- The replacement of missing or lost teeth with artificial teeth. Common procedures are crowns, bridges, dentures, and implants. A prosthodontist is a specialist in this field.
Pulp Chamber- The opening in the center of the crown of a tooth that contains the pulp (nerve tissue) and stretches to the tip of the root.
Quadrant- One fourth of the mouth or half of the bottom or top section of the mouth.
Restoration- A broad term applied to any inlay, crown, bridge, partial denture, or complete denture that restores or replaces loss of tooth structure, teeth or oral tissue. This term applies to the end result of repairing, restoring or reforming the shape, form and function of part or all of a tooth or teeth.
Retainer- An appliance for maintaining the positions of the teeth and jaws immediately after the completion of orthodontic treatment.
Root Canal Therapy- (endodontic therapy) the treatment of a tooth having a damaged pulp. Root Canal Therapy usually includes completely removing the pulp, sterilizing the pulp chamber and root canals, and filling these spaces with sealing material.
Root Planning- The deep cleaning of the teeth to remove hardened plaque below the gum line. This periodontal procedure is typically performed one quadrant at a time, usually by a periodontist or periodontal assistant.
Root Resection- Removing the root of a tooth while retaining the crown. Usually performed by an Endodontist.
Scaling- A treatment for gum disease involving removal of hardened plaque (tartar or calculus) from the teeth. Performed by a dental hygienist during a dental cleaning or in more extreme cases by a periodontist.
Sealant- A thin plastic film painted on the chewing surfaces of teeth to prevent cavities.
TMD (Temporomandibular Disorders)- Problems associated with the temporomandibular joint (TMJ) which connects the lower jaw with the skull. Typically associated with pops and pain in the joint.
TMJD Syndrome - (Temporomandibular Joint). Includes symptoms consisting of pain in the muscles of the mastication and jaw joints, clicking in the jaw joints, and limitation in the jaw movements.
Ultrasonic Cleaning- Tooth cleaning (prophylaxis) that uses high frequency sound waves to gently remove deposits such as tartar and stains from the teeth.
Veneers- Plastic or porcelain which is bonded directly to a tooth to improve its appearance, giving it a very natural appearance.
Whitening- A process of teeth whitening that uses special compounds usually containing hydrogen peroxide. Sometimes lasers are used in conjunction with these compounds. Over-the-counter whitening products are not the prescription strength that dentists use and are therefore less effective.
Wisdom Teeth- The third set of molars that are the last teeth to come in. For many people, wisdom teeth become impacted and must be removed by oral surgery.
X-ray- Radiation used for diagnostic purposes to photograph the bone tissue of the tooth above and below the gum line.