dental care financing terms
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| benefit | amount insurance entity will pay for covered dental services described in its policy
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| Children Health Insurance Program | federal program cover medical care for kids whose families incomes too high to qualify for state medical assistance but can't obtain private insurance, all state participate but some don't cover dental
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| claims processing | entering procedures rendered and determining whether payment will be approved or denied
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| commercial insurance plan | plan that operates for a profit
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| contract | legal agreement b/t an insurance entity and a group/individual
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| deductible | amount an individual enrolled in an insurance plan must pay for covered services before insurance entity begins paying
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| dental claim | patient's formal request for insurance payment for a dental procedure that was rendered
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| dental claim form | standard dental document used to file a claim or request authorization for a procedure
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| managed care | integration of health care delivery and financing
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| medicaid | federal program that distributes funds to states for health care services provided to certain groups including aged, blind, disabled people, those w/ low incomes and certain members of families w/ dependent kids
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| medicare | federal insurance program supported by trust fund, provides limited funding for medically necessary dental services, all people 65+
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| preexisting condition | medical condition that exists prior to person's coverage by insurance entity
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| premium | amount a group or individual pays to insurance for coverage
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| procedure # | ID given to specific procedure as designated in Codes on Dental Procedures and Nomenclature published by ADA
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| provider | legally licensed DH or dentist operating w/in scope of practice
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| dental claim form | standard dental document used to file a claim or request authorization for procedure
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| dental necessity | service provided by dental provider that has been determined as generally acceptable dental practice for a specific diagnosis and tx
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| early and periodic screening, dx, tx | service for persons under 21 for medical, dental, vision, paid for Medicaid
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| exclusive provider arrangement | contract b/t dental care providers and employer stating the negotiated fees for services offered to employers employees
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| explanation of benefits | form sent to patient and provider explaining approval or denial of payment for procedures rendered
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| fee slip | form a dental practice uses to detail the services rendered a patient
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| prepaid group practice | large group of dental providers contracted to provide services to groups of patients
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| single procedure | specific procedure designated by a specific code
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| sound natural teeth | either primary or permanent teeth that have adequate hard/soft tissue support
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| three party system | program in which dental provider renders service for which patient's sponsor (insurance, employer) pays
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| TRICARE (aka Civilian Health and Medical Program of Uniformed Services) | health care program serving active-duty service members, National Guard and Reserve members, retirees, their families, survivors, certain former spouses worldwide,
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| two party system | program in which a dental provider renders service for which patient pays
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| fee for service | fee scale is developed for all services provided by dental provider and payment is then developed for service rendered, most common payment metho din US
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| capitation | dental provider contracts w/ program to provide all/most dental services to program's subscribers in return for payment on per capita basis
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| Barter system | dental provider and patient negotiate payment by exchanging goods or services w/o utilizing money
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| encounter | payment is based on an office visit and is always same regardless of service rendered
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