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Dental reimbursement, PPO networks, CDT codes, and contract language—explained for the people responsible for getting paid correctly.
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Showing all 72 terms
Allowed Amount
The amount a dental plan recognizes for a covered service under its applicable benefit and payment rules; it is not automatically the amount the plan pays.
Read definition Dental codes & benefitsAlternate Benefit
A benefit provision that bases payment on an alternative covered treatment instead of the treatment furnished, subject to plan language.
Read definition Contracting & negotiationsAssignment Clause
A provision governing whether rights or duties under an agreement can transfer to another entity.
Read definition Contracting & negotiationsAudit Rights
Contract provisions permitting review of specified records, claims or payment practices under defined procedures.
Read definition Dental reimbursementBilled Charge
The amount a practice submits on a claim before contractual adjustments, adjudication or patient cost sharing.
Read definition Revenue cycle managementBundling
Treating multiple reported procedures as part of one payable service under applicable payer coding or benefit rules.
Read definition Revenue cycle managementClaim Adjudication
The evaluation of a claim against eligibility, coverage, coding, network and payment rules to determine its disposition.
Read definition Revenue cycle managementClaim Denial
A determination that some or all of a submitted claim is not payable under the applied rules.
Read definition Contracting & negotiationsContract Amendment
A mutually accepted modification to an existing agreement, including fee exhibits or program terms.
Read definition Contracting & negotiationsContract Carve-Out
A provision excluding specified services, codes, specialties or circumstances from a general contract rule.
Read definition Contracting & negotiationsContract Renewal Date
The date an existing agreement renews or its next term begins under the written provisions.
Read definition Dental reimbursementContracted Fee Schedule
The schedule of reimbursable fees attached to or incorporated into a dental participation agreement.
Read definition Dental reimbursementContractual Adjustment
The reduction between a practice's charge and an applicable contracted allowance, when required by the participation agreement.
Read definition Revenue cycle managementCoordination of Benefits (COB)
Rules used to determine how multiple applicable dental coverage arrangements interact on one claim.
Read definition Dental codes & benefitsCore Buildup
A restorative procedure that replaces missing tooth structure to support a crown when clinically indicated; coverage depends on policy and documentation.
Read definition PPO & networksCredentialing vs. Contracting
Credentialing verifies provider qualifications and enrollment criteria; contracting establishes commercial participation terms and rates.
Read definition Dental codes & benefitsCrown Replacement Frequency
A plan rule that limits replacement benefits for existing crowns within a specified number of years or other condition.
Read definition Dental codes & benefitsCurrent Dental Terminology (CDT)
The ADA's dental procedure coding system used to describe services on claims; code descriptions and revisions change by edition.
Read definition Dental codes & benefitsD2740
A CDT code commonly used for a porcelain or ceramic substrate crown, subject to the current code description and documentation rules.
Read definition Dental codes & benefitsD2950
A CDT code for core buildup, including pins when required, under the applicable edition and clinical criteria.
Read definition Dental codes & benefitsD4341
A CDT code for periodontal scaling and root planing involving four or more teeth per quadrant, subject to current coding criteria.
Read definition PPO & networksDirect Payor Contract
An agreement executed between a dental provider organization and the payor or carrier, instead of relying solely on intermediary network access.
Read definition Revenue cycle managementDowncoding
Processing a submitted procedure at a different, generally lower-benefit code or level, when plan provisions allow.
Read definition PPO & networksDownstream Payor
A payor that obtains network access through another contracting entity rather than through a direct provider agreement.
Read definition Dental reimbursementEffective Reimbursement
The revenue actually realized for services after applicable adjudication, mix, adjustments and collection effects; define the calculation before comparisons.
Read definition Revenue cycle managementElectronic Remittance Advice (ERA)
A structured electronic transaction reporting claim payment and adjustment details, commonly through the 835 format.
Read definition Contracting & negotiationsEscalator Clause
A provision that increases fees on a defined schedule or according to an agreed formula.
Read definition Contracting & negotiationsEvergreen Clause
A term causing an agreement to renew automatically unless a party acts under specified conditions.
Read definition Revenue cycle managementExplanation of Benefits (EOB)
An adjudication statement describing claim processing, allowances, payments, denials and member responsibility.
Read definition Contracting & negotiationsFee Loading
The operational process of entering new contracted fee schedules into adjudication and related systems.
Read definition Revenue cycle managementFee Schedule Audit
A review comparing contractual expected fees to payer systems or adjudicated claims for identified CPT or CDT services.
Read definition Dental reimbursementFee Schedule Increase
An agreed upward change to one or more contracted fees, potentially applied uniformly or code by code.
Read definition Dental codes & benefitsFrequency Limitation
A plan limit on how often a covered procedure may receive benefits over a defined period.
Read definition Data & benchmarkingGeographic Market
The area used to select relevant comparison providers and reimbursement observations, whether ZIP, county, metro or another defensible region.
Read definition Data & benchmarkingMachine-Readable File (MRF)
A structured data file published in a format designed for automated processing; qualifying payors publish specified in-network rate information under applicable rules.
Read definition Data & benchmarkingMarket Comparability
The degree to which candidate benchmark rates match relevant code, payment unit, network, payor, geography, time and provider context.
Read definition Dental reimbursementMedicaid Dental Fee Schedule
A state or program-specific schedule listing payment amounts or methodology for eligible dental services, subject to coverage and managed-care arrangements.
Read definition Dental codes & benefitsMissing Tooth Clause
A dental plan limitation that may exclude replacement of teeth missing before coverage began, with variations by contract and jurisdiction.
Read definition Data & benchmarkingModeled Reimbursement Opportunity
An estimate of potential financial change derived from fee differences and assumed or observed utilization, rather than confirmed incremental cash.
Read definition Contracting & negotiationsMost-Favored-Nation Clause
A provision seeking specified pricing treatment relative to rates offered to others; scope and enforceability vary.
Read definition Data & benchmarkingNational Provider Identifier (NPI)
A unique identifier used for health care providers in US administrative transactions; individual and organization NPIs serve different roles.
Read definition Dental reimbursementNegotiated Rate
A rate or fee arrangement agreed between contracting parties for a defined service and covered network; a published rate observation is not proof of a particular practice's executed fee.
Read definition PPO & networksNetwork Access Agreement
A contract governing the terms under which a third party may access a provider network and its negotiated fees.
Read definition PPO & networksNetwork Leasing
The arrangement by which one network grants another payor or entity access to participating providers or negotiated rates, subject to contract terms.
Read definition PPO & networksNetwork Repricing
The process of applying a network's allowed fee or discount arrangement when a claim is adjudicated.
Read definition PPO & networksNetwork Stacking
The presence of multiple possible network relationships for a provider and payor, which may create uncertainty over which arrangement determines a claim fee.
Read definition Contracting & negotiationsNotice Period
The advance interval a contract requires before termination, nonrenewal, repricing or other specified actions.
Read definition Dental reimbursementOut-of-Network Reimbursement
Payment determined when the provider lacks an applicable participating agreement for that benefit, based on the plan's out-of-network rules.
Read definition Data & benchmarkingP25 — 25th Percentile
The rate at or below which approximately one quarter of comparable observations fall, under a defined sampling and weighting method.
Read definition Data & benchmarkingP50 — Median Rate
The middle of a comparable negotiated-rate distribution under the selected method and population; not a guaranteed or universally attainable contract.
Read definition Data & benchmarkingP75 — 75th Percentile
The reference at or below which approximately three quarters of comparable rate observations fall.
Read definition PPO & networksParticipating Provider
A practitioner or entity recognized as in network for a specific plan, product or location under effective participation terms.
Read definition Revenue cycle managementPayment Variance
The difference between anticipated and posted payment for a claim or line, with a defined source of expectation.
Read definition PPO & networksPayor Entity
The specific legal or operational insurer, administrator or contracting organization associated with a plan or published rate, not merely a consumer-facing brand.
Read definition Dental codes & benefitsPosterior Composite Downgrade
A common shorthand for a plan paying benefits based on an alternative material or restoration provision when a posterior composite is furnished.
Read definition Dental codes & benefitsPredetermination
A pre-service estimate or review of expected plan benefits, generally not an unconditional guarantee of payment.
Read definition PPO & networksPreferred Provider Organization (PPO)
A network arrangement in which participating providers accept negotiated terms in exchange for network access and potentially patient volume.
Read definition Contracting & negotiationsRate Hold
A period in which a contract restricts or defers fee changes, subject to the precise wording.
Read definition Data & benchmarkingRate Observation
One recorded rate entry from a source file with associated identifiers and context; not necessarily one contract, provider or claim.
Read definition Revenue cycle managementRecoupment
Recovery or offset of an amount previously paid, following a payer adjustment, review or other applicable process.
Read definition Dental reimbursementReimbursement Variance
The difference between expected and observed reimbursement for a matched service and contractual context.
Read definition Revenue cycle managementRemittance Reconciliation
Matching remittance information to claims, deposits and accounting records to explain each payment and adjustment.
Read definition PPO & networksSilent PPO
A term often used when contracted discounts are accessed through network relationships that the provider did not clearly recognize or expect.
Read definition Data & benchmarkingSource Provenance
Information identifying where data originated and how it was transformed or linked before use.
Read definition Data & benchmarkingTax Identification Number (TIN)
An identifier for the tax-reporting entity associated with a practice or provider group; commonly important in contracting and rate-file provider references.
Read definition Contracting & negotiationsTermination for Convenience
A clause permitting termination without alleging breach when its conditions and notice obligations are satisfied.
Read definition Revenue cycle managementTimely Filing
The deadline by which a claim or required resubmission must be received under governing rules.
Read definition Data & benchmarkingTransparency in Coverage (TiC)
Federal rules requiring many health plans and issuers to disclose specified price information, including applicable in-network rates, with scope and exemptions.
Read definition PPO & networksUmbrella Network
An organization or arrangement connecting multiple underlying payors or networks for contracting or access purposes.
Read definition Dental reimbursementUnderpayment
A payment lower than the amount due under the applicable contractual and benefit terms, after relevant patient responsibility and adjustments are considered.
Read definition Dental reimbursementUsual Customary and Reasonable (UCR)
An imprecise umbrella term used for various fee benchmarks; the meaning and calculation vary by payor and context.
Read definition Dental codes & benefitsWaiting Period
A delay after coverage begins before certain procedures become eligible for specified benefits.
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