Glossary of Dental Insurance Verification Terms

Dental insurance verification is the first step in the dental billing process and it plays a key role in determining whether a patient is covered for a particular treatment or not. Verification errors can lead to claim delays and denials. Dental practices, dental billing, and coding companies as well as medical coders working for insurance companies must be aware of important terminology related to dental insurance verification and dental care.

Here is a list of dental insurance terms and their definitions –

1. Annual Maximum: It refers to the maximum dollar amount the dental insurance company will pay toward the cost of dental services and/or treatment in a benefit plan year. When patients submit dental claims, the insurer subtracts the cost that they have paid for the service from the maximum. Once the annual maximum is reached, patients are responsible for any further expenses. Any deductibles or co-pays that are paid do not count towards annual maximum.
2. Assignment of Benefits: An AOB is an agreement from the patient to transfer the insurance claims rights or benefits of the policy to a third party. Here, the dental office bills directly to the insurance carrier and does not require patients to pay up front for the services their insurance covers.
3. Appeal: An appeal refers to the request made by the dental office to the insurance provider to reconsider paying for a claim or procedure that they have previously refused to pay.
4. Balance Billing: Balance billing is when dental practices bill patients the difference between the dentist’s actual charge and the amount reimbursed under the dental benefit plan.
5. Co-insurance: Co-insurance is the percentage of the dental treatment costs that patients pay for a procedure. Calculated as a percentage of the charged amount, it usually applies after paying the deductible.
6. Co-ordination of benefits (COB): COB occurs when a patient benefits from more than one dental plan and is able to use both of them to cover the treatment procedures.
7. Co-payment or Co-pay: Usually paid at the time of the visit, co-pay refers to a fixed dollar amount that the patients pay for a covered service.
8. Credentialing: Dental credentialing is the process when a dental practice enters into a contract with an insurance carrier to ensure that they are providing the best coverage for every one of their patients. The process involves verification of licenses, specialty certification, malpractice insurance, and more.
9. Discount plans: With this plan, patients can consider signing up on an annual or monthly basis and benefit from significantly reduced rates on dental treatment. Compared to other dental insurance plans, these plans will require more out of pocket payments. To benefit from the applicable discounts, patients must seek treatment from one of the participating dental providers.
10. Explanation of Benefits (EOB): A dental insurance company provides this paper or electronic statement, detailing any dental treatments or services that patients have received. An EOB provides key details, including insurance payments, treatments performed, dentist’s fees, amount you may owe for deductibles, co-pays, and more.
11. Lifetime Maximum: It is the maximum amount a dental plan will cover over the course of a patient’s lifetime. This amount may apply to an individual or a family.
12. Maximum Plan Allowance (MPA): Calculated as a percentile of billed fees, MPA or Maximum Plan Allowance refers to the total dollar amount allowed for a specific benefit.
13. Medically Necessary Care: Medically necessary dental care includes diagnosis, treatment, and follow-up care performed by a dentist for the treatment of any condition, illness, disease, or injury such as – to control infection, restore facial configuration, function necessary for speech, swallowing or chewing and birth developmental malformations.
14. Out-of-pocket Costs: It refers to expenses for dental care that aren’t reimbursed by insurers. This cost includes deductibles, coinsurance, and copayments for covered services along with all costs for services that aren’t covered.
15. Overbilling: Overbilling is billing fees higher than actual charges or billing for something that was actually not performed.
16. Point of Service (POS) Plan: With this dental plan, patients pay less when choosing doctors, hospitals, and other health care providers that belong to the plan’s network.
17. Preauthorization: Also referred to as prior authorization, preauthorization is the advance written approval from the insurer, authorizing the payment for dental services being received by the insured patient. Preauthorization requirements are generally waived for emergency care.
18. Waiting Period: This is the period, when patients might be required to serve a waiting period to be eligible to raise a claim against their dental insurance cover, mainly for expensive services such as dentures or crowns.

An experienced dental insurance verification company can support dental practitioners and their staff to calculate patients’ benefits and claims within the requested period. Outsource Strategies International is one of the leading dental insurance verification companies in the country. Their team is dedicated to helping practices get dental verifications completed ahead of the patient schedule.
Need professional support with insurance verification?

Talk to the OSI team at (800) 670-2809!

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Amber Darst

Amber Darst is our Solutions Manager in the Healthcare Division, Practice and RCM. She is CPC certified by the American Academy of Professional Coders (AAPC). With a rich background in dental services, her expertise ranges from insurance coordination to office management.

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