PA Marketplace Glossary of Dental Terms
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Glossary of Dental Terms DENTAQUEST Pennsylvania INSURANCE TERMS ACA: The Patient Protection and Affordable Care Act of 2010 (Pub. L. 111-148). For example, if the health insurance or plan’s allowed amount for an office visit is $100 and Adverse determination: means a decision by the Plan you’ve met your deductible, your co- or a representative of the Plan to deny, reduce, or insurance payment of 20% would be $20. modify the availability of any dental care services, The health insurance or plan pays the rest of because your condition failed to meet the require- the allowed amount. ments for coverage based on necessity, appropriate- ness of care, level of care, or effectiveness. Co-payment: A fixed amount (for example, $15) you pay for a covered health care Agreement: refers to the Account Dental Service service, usually when you receive the service. Agreement, a contract between the Plan and the Plan The amount can vary by the type of covered Sponsor that provides benefits for dental services. health care service. The Account Dental Service Agreement includes the Subscriber’s Certificate, Schedule of Benefits, Coverage decision: an initial determination by Group Application, Enrollment Form, rates identified in the Plan, or a representative of the Plan that Attachment A, and any applicable Riders, Endorse- results in noncoverage of a health care ments and Supplemental Agreements. service. Coverage decision includes nonpayment of all or any part of a claim, but Appeal: a protest filed by a Covered Individual or a does not include an adverse determination as health care provider with the Plan under its internal defined above. appeal process regarding a coverage decision con- cerning a Covered Individual. Covered dependents: See Family Coverage definition. Balance Billing: When a provider bills you for the dif- ference between the provider’s charge and the allowed Covered individual: a person who is eligible amount. For example, if the provider’s charge is $100 for and receives dental benefits. This usually and the allowed amount is $70, the provider may bill you includes subscribers and their covered for the remaining $30. A preferred provider may not dependents. balance bill you for covered services. Date of service: The actual date that the Co-insurance: Your share of the costs of a service was completed. With multi-stage covered health care service, calculated as a procedures, the date of service is the final percent (for example, 20%) of the allowed completion date (the insertion date of a crown, amount for the service. You pay co-insurance for example). plus any deductibles you owe. covered. Deductible: The amount you owe for Upon the attainment of the limiting age, health care services your health insurance coverage as a Dependent shall be extended or plan covers before your health if the child is and continues to be both (1) insurance or plan begins to pay. For incapable of self-support by rea- son of example, if your deductible is $1000, your intellectual disability or physical handicap, plan won’t pay anything until you’ve met and (2) chiefly dependent upon the your $1000 deductible for covered health subscriber for support and maintenance, care services subject to the deductible. until such time as the coverage The deductible may not apply to all of the subscriber upon whom the child is services. dependent terminates. Subscribers must notify the Plan and provide medical Effective date: the date, as shown on the Plan’s documentation to support this continued records, on which the subscriber’s coverage coverage through the Plan Sponsor within begins under this Agreement or an amendment to seventy-two (72) days of the child’s it. qualifying birthday. Emergency medical condition: a medical Fee Schedule: the payment amount for the condition, whether physical or mental, services that may be provided by manifesting itself by symptoms of sufficient Participating and Non-participating Dentists severity, including severe pain, that the absence under this Agreement and is on file with the of prompt medical attention Virginia Bureau of Insurance. Benefits are could reasonably be expected by a prudent payable in accordance with the terms and layperson who possesses an average knowledge conditions of the applicable Schedule of of health and medicine, to result in placing the Benefits attached to this Agreement and in health of an insured or another person in effect at the time services are rendered. serious jeopardy, serious impairment to body function, or serious dysfunction of any body Filing date: the earlier of a.) five (5) days organ or part or, with respect to a pregnant after the date of mailing; or b.) the date of woman, as further defined in section 1867 (e) receipt. (1)(B) of the Social Security Act, 42 USC section 1395dd(e)(1)(B). Fracture: the breaking off of rigid tooth structure not including crazing due to Emergency dental care includes treatment to thermal changes or chipping due to attrition. relieve acute pain or control dental condition that requires immediate care to prevent permanent Health care provider: any hospital or harm. person that is licensed or otherwise authorized in the Commonwealth of Virginia Family coverage: coverage that includes the Plan to furnish health care services. Sponsor’s eligible employees, their spouse and de- pendent children up to and including twenty- Health care service: the furnishing of a six (26) years of age. You or your spouse’s service to any individual for the purpose adopted children are covered from the date of of preventing, alleviating, curing, or adoptive or parental placement with an insured healing human illness, injury or physical subscriber or plan enrollee for the purpose of disability. adoption, children under testamentary or court appointed guardianship, other than temporary Individual (or single) coverage: coverage guardianship of less than twelve (12) months that includes only the subscriber. duration, and grandchildren in your court-ordered custody who are dependent on you are also Inquiry: any question or concern is not the agent of the Plan. The Plan Sponsor communicated by the Covered Individual or on sends to us the subscription charge due from its the Covered subscribers and receives all notices from the Individual’s behalf, which has not been the Plan to the subscribers. The Plan will send subject of an adverse determination. the Plan Sponsor any subscription refund due to the subscribers. It is the Plan Sponsor’s Medically Necessary: Health care services or responsibility to notify subscribers of changes. sup- plies needed to prevent, diagnose or treat an illness, injury, condition, disease or its Plan Year: a consecutive 12-month period symptoms and that meet accepted standards during which the Plan provides benefits under of medicine. this Agreement. A Plan Year may be a calendar year or otherwise. Non-participating Dentist: a licensed dentist who has not entered into an agreement with Qualified Employer: has the meaning ascribed the to the term in 45 C.F.R. § 155.20. Plan to furnish dental services to its covered individuals. Schedule of Benefits: the part of this Agreement which outlines the specific coverage in effect as Non-Preferred Provider: A provider who doesn’t have well as the amount, if any, that Covered Individuals a contract with your health insurer or plan to provide may be responsible for paying towards their services to you. You’ll pay more to see a non- dental care. preferred provider. Check your policy to see if you can go to all providers who have contracted with your Schedule of Maximum Covered Charges: health insurance or plan, or if your health insurance or see Fee Schedule. plan has a “tiered” network and you must pay extra to see some providers. Service Area: Allegheny - 42003 Beaver - 42007 Open enrollment: a period during which an or- Berks - 42011 ganization allows persons not previously enrolled in Bradford - 42015 the dental plan to apply for dental plan membership. Bucks - 42017 Butler - 42019 Out-of-Pocket Limit: The most you pay during a Cambria - 42021 policy period (usually a year) before your health Centre - 42027 insurance or plan begins to pay 100% of the allowed Chester - 42029 amount. This limit never includes your premium, Clinton - 42035 balance-billed charges or health care your health Columbia - 42037 insurance or plan doesn’t cover. Some health insur- Crawford - 42039 ance or plans don’t count all of your co-payments, Cumberland - 42041 deductibles, co-insurance payments, out-of-network Dauphin - 42043 payments or other expenses toward this limit. Delaware - 42045 Erie - 42049 Participating Dentist: a licensed dentist who has Fayette - 42051 contracted with the Plan to furnish dental services to its Greene - 42059 Covered Individuals. Indiana - 42063 Lackawanna - 42069 Participating Dentist Contract: contract between the Lancaster - 42071 Plan and a Participating Dentist. Lehigh - 42077 Luzerne - 42079 Plan Sponsor: the person or organization that is the Lycoming - 42081 representative of a group plan. In the case of an em- Mercer - 42085 ployment group subject to the Employee Retirement Montgomery - 42091 Income Security Act of 1974 (ERISA, as amended, the Montour - 42093 employer is the Plan Sponsor designated under that Northampton - 42095 act. The Plan Sponsor is the agent of its employees and Philadelphia - 42101 Schuylkill - 42107 Somerset - 42111 Gingivitis: The inflammation of your gums. The first Tioga - 42117 sign of gum disease. Washington - 42125 Westmoreland - 42129 Impacted Tooth: A tooth that is unable to break through Lawrence - 42073 the gums. Subscriber: an employee or member certified by the Plan Sponsor, who is eligible to receive dental Malocclusion: Improper alignment of biting or chewing benefits. A parent or guardian enrolling a minor surfaces of upper and lower teeth. dependent, including under a child-only plan, assumes all of the subscriber responsibilities for Medically Necessary Orthodonture means for the minor dependent.