Insurance Policy Glossary

Some terms you'll need to know in order to understand dental insurance plans:

Usual, Customary, and Reasonable (UCR):

Usual: A dentist's normal charge for a dental procedure.
Customary: A dentist's charge within a range of fees that most dentists in the area charge for a given procedure.
Reasonable: A dentist's charge that is both usual and customary or justified because of special conditions.

Table of Allowances Plan:
A list of covered dental services with an assigned dollar amount that represents the total obligation of the plan with respect to payment for such services but that does not necessarily represent the dentist's full fee for that service.

PPO/EPO:
Preferred Provider Organization (PPO): A formal agreement between a purchaser of a dental plan and a network of dentists who agree to deliver dental services to plan members at discounted fees for cost savings.
Exclusive Provider Organization (EPO): An insurance plan with a network of individual or group dental service providers who have entered into an agreement with an insurer to provide dental insurance to participants. Essentially, an EPO is a much smaller PPO.

HMO:
Health Maintenance Organization (HMO): An HMO is a legal entity that assumes the financial risk for providing specified services to a specified group during a defined period of time for a fixed price. An HMO is also an organized system of dental-care delivery that provides comprehensive dental care to participants through designated providers. Participants are generally assessed a monthly payment for dental services.

Deductible:
A deductible is a portion of any insurance claim that is not covered by an insurance provider. It represents the amount of expenses that must be paid out of pocket by an insured before the insurer will cover any benefit expenses.

Exclusions:
Exclusions are dental services that are not covered under a dental insurance plan. Common exclusions from plans include dental services that are considered cosmetic or which use a dentist who is not approved by the insurance plan.

Limits:
Restrictive conditions in an insurance contract, such as age, length of time covered, and maximum lifetime/annual benefit amounts, affect a participant's or group's coverage. The contract may exclude certain benefits or services or may limit the extent or conditions under which dental services are provided.

Liability:
Liability is any legal responsibility, duty, or obligation for a specified amount or action that is either due now or at some time in the future.

Premium:
A premium is the amount charged by a dental benefit provider for coverage of a certain level of benefits for a specified time. A premium is also the periodic payment on an insurance policy.

Claim:
A claim is a notification to an insurance company requesting payment of a certain amount under the terms of an insurance policy. A claim is also an application for benefits by an insurance policyholder.