A comprehensive reference of dental billing and insurance terminology used by dental practices, DSOs, and dental billing professionals. Each term includes a plain-language definition designed for office managers, treatment coordinators, and billing specialists.
The standardized coding system maintained by the American Dental Association (ADA) used to document and report dental procedures on insurance claims. CDT codes are updated annually and organized by procedure category (diagnostic, preventive, restorative, endodontics, periodontics, prosthodontics, oral surgery, orthodontics).
A request submitted to a dental insurance carrier before treatment begins to determine what benefits will be paid. The predetermination shows the estimated patient responsibility and insurance coverage. Unlike prior authorization, predetermination is not binding.
The process of confirming a patient's dental insurance eligibility, remaining benefits, annual maximums, deductible status, waiting periods, frequency limitations, and covered procedures before treatment begins. Verification prevents balance billing surprises and claim denials.
The maximum dollar amount a dental insurance plan will pay for covered services within a plan year (typically January-December or the member's renewal date). Once the annual maximum is reached, the patient is responsible for 100% of remaining costs. Most plans have maximums between $1,000-$2,500.
A period of time (typically 6-12 months) after a dental insurance policy begins during which certain categories of procedures are not covered. Waiting periods commonly apply to basic procedures (fillings, extractions) and major procedures (crowns, bridges, dentures) but typically not preventive care.
Insurance plan restrictions on how often certain procedures are covered. Common examples: prophylaxis (cleaning) covered twice per year, bitewing X-rays covered once per year, panoramic X-ray covered once every 3-5 years, crown replacement covered once every 5-10 years.
A documented plan created by the dentist outlining recommended dental procedures, their sequence, estimated costs, and expected insurance coverage. Treatment plans are presented to patients for informed consent and to insurance carriers for predetermination.
The standardized form (ADA Dental Claim Form, version J430D) used to submit dental insurance claims electronically or on paper. The form includes patient information, provider information, procedure codes (CDT), tooth numbers/surfaces, and diagnosis codes.
The numbering system used in the US to identify individual teeth. Adult teeth are numbered 1-32 starting from the upper right third molar (#1) and ending at the lower right third molar (#32). Primary (baby) teeth use letters A-T.
The coding system used to identify which surfaces of a tooth are affected by a procedure. The five surfaces are: Mesial (M), Distal (D), Occlusal (O), Buccal/Facial (B/F), and Lingual (L). A filling on two surfaces is called a two-surface restoration (e.g., MO, DO, MOD).
The fee that an insurance carrier considers standard for a particular dental procedure in a specific geographic area. Insurance reimbursement is often based on UCR fees, and dentists who charge above UCR may leave patients responsible for the difference (balance billing).
A type of dental insurance network where dentists agree to accept reduced fees (contracted rates) in exchange for patient referrals. Patients pay lower out-of-pocket costs when seeing in-network PPO dentists.
A managed care dental plan where patients select a primary care dentist from the network and receive services at reduced copayments. Referrals are typically required for specialist care, and out-of-network services are generally not covered.
The process of determining payment responsibility when a patient has dual dental insurance coverage. The primary plan pays first based on standard COB rules (birthday rule for dependent children, subscriber rule for adults), and the secondary plan covers remaining eligible amounts.
When a dental insurance carrier reimburses for a less expensive procedure than what was performed and billed. For example, a carrier might reimburse a porcelain crown (D2740) at the rate for a base metal crown (D2751) if they determine the less expensive material is adequate.
When an insurance carrier denies a separately billed procedure because they consider it part of another procedure that was billed simultaneously. For example, a carrier might bundle a core buildup (D2950) into a crown (D2740) and deny separate payment.
A written explanation attached to a dental insurance claim that provides clinical justification for a procedure. Narratives are typically required for procedures the carrier considers potentially not medically necessary, such as crown replacements before the standard frequency limitation.
A dental insurance provision that excludes coverage for dental conditions that existed before the policy's effective date. Some plans apply this to missing teeth — if a tooth was lost before coverage began, replacement (bridge, implant, partial) may not be covered.
A widely used dental practice management software developed by Henry Schein. Dentrix handles scheduling, patient records, treatment planning, billing, insurance claims, and reporting. It is one of the most common systems Edge dental professionals are certified to use.
A dental practice management software developed by Patterson Dental. Eaglesoft provides scheduling, clinical charting, billing, imaging, and insurance management functionality. Commonly used in single and multi-location dental practices.
An open-source dental practice management software known for customizability and integration capabilities. Open Dental handles scheduling, charting, billing, imaging, and reporting with extensive API access for third-party integrations.
Edge Edu certifies every professional on industry-specific terminology, workflows, and systems before placement.
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