Dental Insurance Glossary

A

Abscess

A painful collection of pus caused by a bacterial infection, usually near the tooth root or gumline, leading to swelling and discomfort.

Abutment

A natural tooth or dental implant that provides support for a bridge, crown, or denture by anchoring the restoration in place.

Alternative Benefit  

The benefit amount your insurance pays for a less expensive but acceptable dental treatment that meets the same need.

Amalgam

A traditional silver-colored dental filling material made from a mix of metals, known for its strength and durability in back teeth.

Anesthesia

A method used to block pain during dental procedures. It can be local (numbing a specific area) or general (putting the patient to sleep).

Annual Maximum  

The maximum dollar amount your insurance will pay for covered services within a calendar year. Once you reach this limit, you’ll be responsible for any additional costs.

Apicoectomy
A minor surgical procedure that removes the tip of a tooth’s root when standard root canal treatment hasn’t resolved an infection.

Assignment of Benefits

Authorization by a patient allowing the insurer to pay benefits directly to the provider, reducing the need for the patient to pay upfront.

B

Balance Billing

When a provider bills you for the difference between their charge and the allowed amount by your insurance. This happens when using out-of-network providers. The practice where an out-of-network provider bills the patient for the difference between their fee and the insurer's allowed amount.

Basic Services 

Common dental treatments such as fillings, extractions, and simple restorative procedures. These services typically require coinsurance or copayments.

Benefit Schedule 

A list detailing the specific amounts that the insurance will pay for various covered services, regardless of the actual charges.

Benefit Year

The 12-month period during which your dental insurance benefits reset. It typically aligns with the calendar year but can vary.

Bitewing X-ray
A type of dental X-ray that captures images of the upper and lower teeth in one area to help detect cavities and bone loss.

Bleaching (Teeth Bleaching)
A cosmetic dental procedure that uses peroxide-based agents to lighten the natural color of teeth and remove stains from substances like coffee, tea, or tobacco.

Also known as: Teeth whitening, tooth bleaching.

Bonding
A cosmetic dental procedure where tooth-colored resin is applied to repair chips, cracks, or gaps and improve tooth appearance.

Bridge
A dental restoration that fills the gap left by one or more missing teeth, typically anchored by surrounding teeth or implants.

Bruxism
The involuntary grinding or clenching of teeth, often occurring during sleep and potentially leading to enamel wear or jaw pain.

C

Calculus (Tartar)
Hardened plaque that forms on teeth when not removed through daily brushing and flossing. It can lead to gum disease and requires professional cleaning.

Canker Sore
A small, round sore inside the mouth that can be painful when eating or talking. It’s not contagious and usually heals on its own.

Capitation

A fixed payment made to a dentist by a dental plan, typically in DHMO plans, regardless of how many services the patient uses.

Capitation Plan  

A dental plan in which dentists receive a set amount for each enrolled patient, regardless of whether that patient seeks care.

Caries
Another term for tooth decay or cavities, caused by the breakdown of tooth enamel from acids produced by bacteria.

Cementum
A hard tissue that covers the roots of teeth, helping to anchor them in the jaw by connecting to ligaments.

Certificate of Coverage

A document provided by the insurer outlining the terms, benefits, exclusions, and conditions of coverage.

Claim

A request for payment that you or your dentist submits to the insurance company for services you believe are covered.

Claim Adjudication

The process by which an insurance company reviews and processes a submitted claim to determine the payment amount.

Claim Form 

The document that must be completed and submitted to request reimbursement from the insurance company for covered services.

Coinsurance  

The percentage of covered dental expenses you’re responsible for after meeting your deductible. For instance, if your coinsurance is 20%, you pay 20% of the cost, and the insurance covers the remaining 80%. The percentage of costs the patient pays for covered services after meeting the deductible (e.g., the plan pays 80%, the patient pays 20%).

Composite Resin
A tooth-colored material used in fillings and restorations that bonds directly to the tooth and blends in naturally.

Coordination of Benefits (COB)

When you have multiple insurance policies (e.g., through your employer and your spouse’s employer), COB determines which plan pays first and how much the secondary plan covers. This process ensures coverage without exceeding the cost of services.

Copayment (Copay)

A fixed fee you pay for specific dental services (e.g., cleanings, fillings) at the time of the visit. Copayments vary based on the service provided. A fixed amount the patient pays for a specific dental service at the time of the visit.

Covered Charges  

The fees for dental services that are covered under your dental plan, subject to limitations and conditions of your policy.

Credentialing

The process of verifying a dentist's qualifications before they are allowed to participate in an insurance network.

Crown
A custom-made cap placed over a damaged tooth to restore its shape, size, and function, while protecting the remaining tooth structure.

Cusp
The raised point or ridge on the chewing surface of a back tooth that helps break down food.

G

General Dentist

A primary dental care provider who diagnoses, treats, and manages overall oral health care needs. Services may include cleanings, fillings, crowns, bridges, and preventive education.

Gingiva
The soft tissue, commonly known as gums, that surrounds and protects the base of the teeth and bone. 

Gingivitis

A mild form of gum disease (periodontal disease) that causes irritation, redness, and swelling of the gums. It is typically caused by plaque buildup and is reversible with proper oral hygiene. The earliest stage of gum disease, causing redness, swelling, and bleeding of the gums, often due to plaque buildup.

Gingivectomy

A surgical procedure to remove and reshape loose, diseased gum tissue to eliminate pockets between the teeth and gums. Often performed to treat advanced gum disease or for cosmetic purposes, or improve aesthetics.

Group

A defined body of individuals—such as employees of a company or members of an organization—who are eligible for coverage under a group dental insurance plan provided by their employer or sponsor.

Guaranteed Issue

A type of policy that is issued without the applicant having to undergo medical underwriting. In dental insurance, this means coverage is provided regardless of health history or pre-existing conditions.

H

Health Maintenance Organization (HMO)

A type of dental insurance plan that typically requires members to receive care from a defined network of dentists. HMOs often have lower premiums and focus on preventive care but usually do not cover out-of-network services except in emergencies.

Health Savings Account (HSA)

A tax-advantaged savings account used in conjunction with a high-deductible health plan (HDHP). Funds contributed to an HSA can be used to pay for qualified medical and dental expenses, and they roll over year to year if not spent.

High Deductible Health Plan (HDHP)

A health insurance plan that features higher deductibles and lower premiums. Often paired with a Health Savings Account (HSA), HDHPs can be used for dental expenses until the deductible is met.

HIPAA (Health Insurance Portability and Accountability Act)

A federal law that protects the privacy and security of an individual’s health information. In the context of dental insurance, HIPAA ensures that personal health data is kept confidential and outlines patients’ rights regarding their health records.

I

Implant
A titanium post surgically placed in the jaw to act as a foundation for a replacement tooth or dental prosthesis.

Impression
A mold or replica of the teeth and gums taken by a dentist to create crowns, bridges, dentures, or aligners.

Incentive Plan 

A type of dental plan where coverage levels increase when you maintain regular dental visits and do not exceed certain limits on claims.

Indemnity Plan  

A type of dental plan that reimburses you or the provider for covered services, regardless of which dentist you see. You may need to pay upfront and submit a claim for reimbursement.

Inlay
A custom-fitted filling designed to fit within the grooves of a tooth without covering the cusps. 

In-Network / Out-of-Network

“In-Network” providers have agreed to contracted rates with the insurer. “Out-of-Network” providers have not, often resulting in higher patient costs.

M

Malocclusion
An improper alignment of the teeth or jaws, which may cause bite problems or cosmetic concerns.

Mandible
The lower jawbone, responsible for holding the lower teeth and enabling mouth movement.

Major Services  

More complex treatments, including crowns, bridges, dentures, root canals, and orthodontics. These services often have higher coinsurance or copayments.

Maxilla
The upper jawbone, which supports the upper teeth and forms part of the nose and eye socket structures.

N

Negotiated Fee

The reduced fee that in-network dentists agree to accept from the insurer as full payment for covered services.

Network  

Dentists and dental facilities that have agreements with the insurance carrier. In-network providers typically offer discounted rates to insured individuals.

Non-Covered Services  

Dental procedures that are not included in your dental insurance plan benefits. Patients must pay the full cost for these services.

O

Occlusion
The way upper and lower teeth fit together when biting or chewing. Proper occlusion ensures even pressure and balance. 

Onlay
A custom-made restoration that covers one or more cusps of a tooth, offering more protection than an inlay but less than a crown.

Open Enrollment Period  

A specific time frame during which you can sign up for or make changes to your dental insurance plan without needing a qualifying event. A specific time each year when individuals can enroll in, change, or cancel dental insurance coverage.

Orthodontics 

Dental treatment to correct misaligned teeth using braces, aligners, or other appliances. Coverage for these treatments may have a lifetime maximum. A dental specialty focused on correcting alignment issues with teeth and jaws using braces, aligners, or other appliances.

Out-of-Network  

Dentists who are not part of the insurance carrier’s network. If you choose an out-of-network provider, your costs may be higher.

T

Takeover

When a new dental insurance provider assumes responsibility for continuing coverage from a previous plan, often to avoid any lapse in benefits.

Temporomandibular Joint (TMJ)

The joint that connects the lower jaw to the skull. Disorders in this joint can cause jaw pain, headaches, difficulty chewing, and other symptoms. The hinge joint connecting the jaw to the skull, enabling movement for speaking and chewing. Disorders in this joint can cause pain and dysfunction.

Third-Party Administrator (TPA)

An organization that manages dental insurance claims and administrative services on behalf of an insurance company or employer, but does not bear insurance risk.

Tooth Erosion
The gradual loss of enamel due to acid exposure, commonly from diet, reflux, or medical conditions.

Tooth Sensitivity
Pain or discomfort in teeth triggered by hot, cold, sweet, or acidic stimuli, often due to exposed dentin.

U

Ulcer
A sore inside the mouth or on the gums that can cause pain or irritation and may result from injury, infection, or systemic issues.

Unerupted Tooth

A tooth that has not emerged through the gum and is still beneath the surface, which may require monitoring or treatment.

Unilateral

A condition or treatment that affects only one side of the mouth or face.

Usual and Customary (U&C)

A standard used by insurance providers to determine reimbursement amounts for dental services based on average charges in a specific geographic area.

V

Veneer

A thin shell of porcelain or resin bonded to the front surface of a tooth to improve its color, shape, or alignment.

Vertical Dimension

The measurement of facial height between the upper and lower jaws when the teeth are in contact. It is important for proper bite and aesthetics.

Voluntary Plan

A dental insurance plan that individuals can choose to enroll in, typically offered through an employer, where the enrollee pays most or all of the premium.

W

Waiting Period

A set amount of time an individual must wait before specific dental benefits become available under an insurance plan.

Wisdom Teeth

The third and final set of molars, usually emerging in late teens or early adulthood. They may need removal if they are impacted or cause crowding. The last set of molars that typically emerge in late adolescence or early adulthood, often removed due to alignment or crowding problems.

X

Xerostomia

A condition commonly referred to as dry mouth, caused by reduced saliva flow. It can increase the risk of tooth decay and gum disease.

X-Ray

An imaging technique used in dentistry to view structures inside the teeth and jaw that are not visible during a regular examination.

Y

Yeast Infection

A fungal infection in the mouth, also known as oral thrush. It can cause white patches, redness, and discomfort on the tongue and inner cheeks.

Z

Zirconia Crown

A dental crown made from zirconium dioxide, known for its strength, biocompatibility, and tooth-like appearance.

Zygomatic Implant

A type of dental implant anchored in the cheekbone, used when the upper jaw lacks enough bone for conventional implants.