Glossary
A
Access Point
Anywhere a member can go to receive high-quality dental care and the best way to demonstrate the value of our network as it focuses on the ease of member access to care.
Affordable Care Act (ACA)
A new, comprehensive law passed in 2010, aimed at reforming America’s health care system to improve access and affordability for more Americans.
American Association of Dental Office Managers (AADOM)
An organization of professional office managers, practice administrators, patient coordinators, insurance and financial coordinators, and treatment coordinators of general and specialized dental practices. It is the goal of the Association to create and maintain a network of dental office managers throughout the country in order to share resources and information to achieve the highest level of professional development.
American Dental Association (ADA)
Founded in 1859, the not-for-profit ADA is the nation's largest dental association, representing 157,000 dentist members. It has grown to become the leading source of oral health related information for dentists and their patients.
Average Discount
A DenteMax sales tool that illustrates the average off of a procedure code savings by using the DenteMax Network.
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Balance Bill
Billing a patient for the difference between the dentist’s actual charge and the amount reimbursed under the patient’s dental benefit plan.
Basic Services
Dental procedures designated by a benefit plan that often include a broad range of services: endodontics (treatment of root canals), periodontics (uncomplicated treatment for gum diseases), and prothodontics (treatment for repair of existing dentures and bridges).
Benefits
The health care items or services covered by an insurance plan. Your insurance plan may sometimes be referred to as a “benefit package.”
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CDT Code Analysis
A DenteMax sales tool that illustrates what the DenteMax fee and the average dentist fee is for a certain area and procedure code.
Centers for Medicare and Medicaid Service (CMS)
The Centers for Medicare & Medicaid Services (CMS), a federal agency and branch of the U.S. Department of Health & Human Services, administers Medicare, Medicaid and the Children’s Health Insurance Program (CHIP) program in partnership with state governments, and private health insurance programs including Health Insurance Marketplaces, and provides information for health professionals, regional governments, and consumers.
Charge Amount
The amount charged or billed by the dentist for a claim.
Commercial Network
The primary DenteMax PPO network which has more than accesspoint dentist access points nationwide. Referred to as ‘the network’.
Competitive Comparison
A DenteMax sales tool that measures DenteMax against our competitor networks and can be compared by state, city, county, or zip code.
Controlled Dangerous Substances (CDS)
Any drug or therapeutic agent–commonly understood to include narcotics, with a potential for abuse or addiction, which is held under strict governmental control, as delineated by the Comprehensive Drug Abuse Prevention & Control Act passed in 1970. A state certificate is needed to allow a dentist to administer or dispense these substances.
Covered Amount
The maximum dollar amount on which benefit payment is based for each dental procedure.
Client Partner
DenteMax leases its network to its client partners - insurance companies, third-party administrators and various groups and organizations.
Credentialing
A formal process that defines the standards and requirements for participation in third-party programs. The process verifies professional qualifications in order to allow licensed dentists to provide services to members of these programs.
Credentialing Verification Organization (CVO)
An external organization that contracts with a health plan to handle all provider credentialing requirements. These organizations may also be subject to accreditation requisites, according to state regulations.
Current Dental Terminology (CDT)
The ADA reference manual that contains the Code on Dental Procedures and Nomenclature and other information pertinent to patient record keeping and claim preparation by a dental office; published biennially.
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Deductible Amount
The amount of dental expense for which the beneficiary is responsible before a third party will assume any liability for payment of benefits. Deductible may be an annual or one-time charge, and may vary in amount from program to program.
Dental Solutions
DenteMax’s discount dental card where participating providers have agreed to accept a discounted fee from plan members as payment in full for services performed.
Diagnostic Services
Dental procedures which includes examinations to determine the existence of dental disease, X-rays and routine oral examinations.
Directory
A listing of DenteMax Dentists location information in specific areas.
Discount Card
Members purchase access to the network for themselves and/or family and present a membership card to participating dentists as an alternative to insurance. When a member visits a participating dentist, the member is charged according to the reduced DenteMax fee schedule, with payment due at the time of service.
Disruption
A DenteMax sales tool that illustrates how many member dentists are currently in or out of network. Out of network dentist information can be used for recruitment efforts.
Drug Enforcement Administration (DEA)
A federal agency responsible for enforcing laws and regulations governing narcotics and controlled substances.
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Endodontist (EN)
Treats problems with the nerve of the tooth. Performs root canal treatments, root amputation (removing a root on a multi-rooted tooth) and apicoectomy (surgically removing the tip of the root).
Explanation of Benefits (EOB)
A written statement to a beneficiary from a third-party payer, after a claim has been reported, indicating the benefit/charges covered or not covered by the dental benefit plan.
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Fee Schedule
A list of the charges established or agreed to by a dentist for specific dental services.
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General Dentist (GP)
General family dentist without additional specialty training.
GEONetworks Access Report
A DenteMax sales tool that uses a group’s census data to show how the DenteMax providers match up geographically for the group’s membership.
Group
A group of people covered under the same health care plan and identified by their relation to the same employer or organization.
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Health Insurance Portability and Accountability Act (HIPPA)
A federal law that outlines the rules and requirements employer-sponsored group insurance plans, insurance companies and managed care organizations must follow to provide health care insurance coverage for individuals and groups.
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Individual Membership Program
The DenteMax Individual Membership Program is an alternative to dental insurance. Members purchase access to the network for themselves and/or family and present a membership card to participating dentists. When a member visits a participating dentist, the member is charged according to the reduced DenteMax fee schedule, with payment due at the time of service.
In-network
Referring to the inclusion of a dentist in a network arrangement, and with whom a plan or type of benefit has an agreement to provide care for its members. Usually, a member will pay less out of your own pocket when receiving treatment from in-network providers.
M
Major Services
Dental procedures designated by a benefit plan that services may include gold restorations and crowns, oral surgery, and dental implants.
MaxPlus Program
A program provided to participating DenteMax dentists providing exclusive savings on products and services from respected industry leaders that DenteMax has partnered with.
Medicare Network
The DenteMax Medicare Network indicates those dentists who participate in Medicare plans. Supplemental Medicare plans offer benefits that are not normally covered under traditional Medicare. Some supplemental plans cover preventive dental benefits.
Member
An individual enrolled in a dental benefit program.
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National Association of Dental Plans (NADP)
NADP is the largest non-profit, national trade association focused exclusively on the entire dental benefits industry, i.e. dental HMOs, dental PPOs, discount dental plans and dental indemnity products.
National Committee for Quality Assurance (NCQA)
The National Committee for Quality Assurance is a private, 501(c)(3) not-for-profit organization. NCQA manages voluntary accreditation programs for individual physicians, health plans, and medical groups.
National Practitioner Data Bank (NPDB)
The National Practitioner Data Bank (NPDB), or "the Data Bank," is a confidential information clearinghouse created by Congress with the primary goals of improving health care quality, protecting the public, and reducing health care fraud and abuse in the U.S.
National Provider Identifier (NPI)
This is an identifier assigned by the federal government to all providers considered to be HIPAA covered entities. Dentists who are not covered entities may elect to obtain an NPI at their discretion, or may be enumerated if required by a participating provider agreement with a third-party payer, or applicable state law/regulation. An NPI is unique to an individual dentist or dental entity, and has no intrinsic meaning. There are two types of NPI available to dentists and dental practices: Type 1 Individual Provider - A health care practitioner who is a single human being. ALL dentists are eligible to apply for Type 1 NPIs, regardless of whether they are covered by HIPAA. Type 2 Organization Provider - A health care provider that is an organization, such as a group practice or corporation. Individual dentists who are incorporated may enumerate as Type 2 providers, in addition to being enumerated as a Type 1. All incorporated dental practices and group practices are eligible for enumeration as Type 2 providers.
Network
The group of dentists that a managed care plan has contracted with to deliver services to its members.
Non-Covered Services Legislation
Laws that prohibit insurance companies from controlling what a dentist may charge for services dental benefit plans don’t cover.
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Office Managers Advisory Council (OMAC)
The DenteMax OMAC is a diverse team of dental office managers that provides input into how DenteMax can best meet the needs of our dental office partners.
Office of Inspector General (OIG)
Since its 1976 establishment, the Office of Inspector General of the U.S. Department of Health & Human Services (HHS) has been at the forefront of the Nation's efforts to fight waste, fraud, and abuse in Medicare, Medicaid and more than 300 other HHS programs.
Oral and Maxillofacial Pathology (OP)
A dental specialist whose practice is concerned with recognition, diagnosis, investigation and management of diseases of the oral cavity, jaws, and adjacent structures.
Oral and Maxillofacial Radiology (OD)
A dental specialist whose practice is concerned with the production and interpretation of images and data produced by all modalities of radiant energy used for the diagnosis and management of diseases, disorders and conditions of the oral and maxillofacial region.
Oral Surgeon (OS)
Performs surgery in the head area, including: simple and complex extractions involving removal of soft tissue or overlying bone or remaining roots, impacted teeth (especially wisdom teeth), soft tissue biopsies, removal of tumors, implant placement, complex jaw realignment surgeries (orthognathic surgery) involving facial or bite discrepancies, jaw or facial fracture stabilization (repair of fractured cheek or jaw bones) and repair of soft tissue problems (cleft palate or lip).
Orthodontist (OR)
Straightens patient's teeth through movement of the teeth through bone by the use of bands, wires, elastics, headgears and other fixed or removable appliances or retainers.
Out-of-Network
Services provided by dentists who have not contracted with your health plan.
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Participating Provider Option (PPO)
A formal agreement between a purchaser of a dental benefit program and a defined group of dentists for the delivery of dental services to a specific patient population, as an adjunct to a traditional plan, using discounted fees for cost savings.
Pedodontist (PD)
Focuses on younger patients from children as young as one or two to early adulthood. Can detect and treat.
Periodontist (PE)
Deals with soft tissue of the mouth and the supporting structures (bone) of the teeth. Treats gingivitis (inflammation of the gingival tissue) as well as periodontitis (gingival tissue and bone disease). Performs simple and deep pocket cleanings, root planning, crown lengthening, soft tissue and/or bone grafting, gingival or flap procedures, soft tissue recontouring or removal (gingivoplasty or gingivectomy), hard tissue recontouring (osteoplasty) and implant placement.
Plan Payment Amount
The amount a claim that is paid by a benefit plan.
Plus Network
The DenteMax brand name used for any stacked network we offer to our client partners.
Preventive Services
Dental procedures to preserve and maintain dental health. Topical cleaning, space maintainers, fluoride treatments fall into this category.
Procedure Code
A code used to identify dental services on the patient record as well as for reporting dental services and procedures to dental benefit plans.
Prosthodontist (PR)
Deals with simple to complicated full-mouth restorations or full-mouth rehabilitation. Performs crowns, fixed bridges, partial dentures, full dentures, overdentures, implant reconstruction, full mouth reconstruction/occlusal rehabilitation, cosmetic dentistry, treatment of temporomandibular/orofacial pain disorders.
Provider
A licensed dentist that delivers services.
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Recruitment
DenteMax will seek to enroll into our network both dentists currently being utilized by our members, as well as dentists who are known to participate with other PPO networks. All providers must meet DenteMax's stringent credentialing criteria before admittance into our network.
Reprice
A DenteMax sales tool that assigns the DenteMax fee to claims provided by a group as if they have been processed using the DenteMax Network.
RFI/RFP
Requests for Proposal (RFP) and Requests for Information (RFI) are questionnaires about our network to determine if DenteMax would be a good network fit for a group or administrator.
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Savings Analysis
A DenteMax sales tool that is used to illustrate the claim savings that can be gained by adding the DenteMax network to a dental program using a group’s claim data provided to us.
Specialist
A dentist whose practice is limited to a certain branch of dentistry.
Stacked Network
Combines two or more PPO networks together into one seamless network.
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Tax ID (TIN)
A number which is used to identify entities for tax-related purposes such as filing tax returns, or other actions such as opening a bank account.
Third-Party Administrator (TPA)
Claims payer who assumes responsibility for administering health benefit plans without assuming any financial risk. Some commercial insurance have TPA operations to accommodate self-funded employers seeking administrative service only contracts.
U
Usual Fee
The fee that an individual dentist most frequently charges for a given dental services. Often used to describe a level of reimbursement that insurers use to calculate reimbursements for out-of-network care. If your plan covers some out-of-network care, your insurer may base the payment on a price that it determines to be “usual, customary and reasonable” in your area.
Utilization Review Accreditation Committee (URAC)
URAC, an independent, nonprofit organization, is well-known as a leader in promoting health care quality through its accreditation, education and measurement programs.
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