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Glossary of Terms


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Abrasion: The loss of tooth structure caused by a hard toothbrush, poor brushing technique, or Bruxism (grinding or clenching the teeth).

Abscess: A localized infection in the bone or soft gum tissues, usually at the end of the root tip.

Abutment: The natural tooth that holds in place a fixed or removable bridge

Air Abrasion: Tiny particles of aluminum oxide blasted in a stream of water at the tooth to remove the decayed debris and ruined enamel of cavities.

Allergy: Unfavorable systemic response to a foreign substance or drug.

Alveolar Bone: The jaw bone that anchors the roots of teeth.

Amalgam: The most common filling material used for fillings, also referred to as mercury or silver.

Analgesia: A state of pain relief; an agent to lessen pain.

Anesthesia: Relieves the sensation of pain. See General Anesthesia, IV Sedation and Local Anesthesia.

Anterior Teeth: The six upper or six lower front teeth.

Antibiotic: A drug that stops or slows the growth of bacteria.

Apex: The tip of the root of a tooth.

Apicoectomy: The surgical removal of the root tip to treat a dead tooth.

Arch: Describes the alignment of the upper or lower teeth.

Attrition: Loss of structure due to natural wear.

Autoclave: A device that has a chamber where instruments are placed and steam under pressure is injected, in order to complete sterilization.

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Base: Cement placed under a dental restoration to insulate the nerve chamber.

Bicuspid or Pre-Molar: Transitional teeth behind the cuspid.

Biopsy: Removal of a small piece of tissue for microscopic examination.

Bite: The way in which the upper and lower teeth meet when closing the mouth.

Bite Wings: Decay detection x-rays.

Bleaching: Chemical or laser treatment of natural teeth for whitening effect.

Bonding: The covering of a tooth surface with a composite resin, to correct stained or damaged teeth.

Braces: Devices used by Orthodontists to gradually reposition teeth.

Bridge: Prosthetic (false) teeth or row of teeth that spans between two natural teeth.

Bruxism: Involuntary, “nervous” grinding of the teeth while the patient is asleep.

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Calcium: Chemical element needed for healthy teeth, bones and nerves.

Calculus: Hard residue, commonly know as “tartar”, that forms on teeth due to inadequate plaque control often stained yellow or brown.

Canker Sore: Mouth sores appearing whitish, often with a red halo.

Cantilever Bridge: Fixed bridge that attaches to adjacent teeth only on one end.

Cap: Common term for dental crown (See Crown).

Cavities: A decay lesion or hole in a tooth.

Clasp: Device that holds a removable partial denture to stationary teeth.

Cleaning: Removal of plaque and tartar from teeth, generally above the gum line.

Composite Filling: A tooth-colored filling that looks like a natural tooth.

Cosmetic Dentistry: Treatments performed to enhance appearance (e.g., bleaching, veneers).

Crown: A porcelain or gold cover for a decayed, damaged, or discolored tooth.

Cross Bite: Reverse biting relationship of upper and lower teeth, e.g., “under bite”.

Curettage: Removal of diseased tissue from a periodontal pocket.

Cuspid: The large pointed teeth at the corners of the mouth, located between the incisors and bicuspids. Also known as canine or eyeteeth.

Cusps: The raised round parts on the chewing surface of the teeth.

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DDS: Doctor of Dental Surgery

DMD: Doctor of Medical Dentistry

Decay: Destruction of tooth structure caused by toxins produced by bacteria.

Deciduous Teeth: Commonly called “baby teeth”, the first set of (usually) twenty teeth.

Dentin: Inner layer of tooth structure, immediately under the surface enamel.

Dental Floss: A waxed or unwaxed piece of nylon string that is inserted between the teeth and moved in an up/down fashion for the removal of plaque or other food deposits.

Dental Implant: Usually a titanium cylinder surgically placed in the bone of the upper or lower jaw to provide support for a dental restoration or appliance.

Dentition: The arrangement of natural or artificial teeth in the mouth.

Denture: Removable (partial or complete) set of artificial teeth.

Diastema: Space between teeth.

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Enamel: The hard tissue covering the portion of tooth above the gum line. This is the hardest substance in the body.

Endodontics: The branch of dentistry concerned with the treatment of the dental pulp or nerve of the tooth. The most common procedure is a root canal.

Endodontist: A specialist who treats injuries, diseases and infections of the tooth pulp.

Extraction: Removal of a tooth.

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Facing: Tooth colored overlay on the visible portion of a crown.

Filling: Restoration of lost tooth structure with metal, porcelain or resin materials.

Flap Surgery: Lifting of gum tissue to expose and clean underlying tooth and bone structures.

Fluoride: A chemical that is used to strengthen the teeth.

Frenectomy: Removal or reshaping of thin muscle tissue that attaches the upper or lower lips to the gum, or the tongue to the floor of the mouth.

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General Anesthesia: A “deep sleep” general anesthesia renders you unconscious.

Gingivectomy: Surgical removal of gum tissue.

Gingivitis: Inflammation of gum tissue, early stage of gum disease.

Gum Recession: Exposure of dental roots due to shrinkage of the gums as a result of abrasion, periodontal disease or surgery.

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Halimeter: An instrument used in the diagnosis and treatment of chronic halitosis.

Halitosis: Bad breath.

Heat Sterilization: A procedure that involves a chamber into which instruments are placed and which raises the temperature for a period of time to kill all microorganisms.

Hygienist: A type of dental professional qualified to clean and scale teeth. They also educate patients on proper dental care.

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Imaging: A photograph of teeth stored in a computer and then displayed on a television monitor. The dentist is able to show you an image of your smile with new, repaired or whitened teeth.

Impacted Tooth: A tooth that fails to erupt properly and remains fully or partially embedded and covered over by bone or gum tissue.

Implant: A fixed replacement for a missing tooth.

Impression: Mold made of the teeth and soft tissues.

Incisors: The four upper or lower single-cusped front teeth designed for incising or cutting food.

Inlay: A custom made cast-gold alloy that is cemented to a previously prepared cavity in the tooth.

Interproximal: Surfaces of adjoining teeth.

Interocclusal: Space between upper and lower teeth.

Intraoral camera: A small video camera used to view and magnify oral conditions; images may be viewed on a monitor or printed.

IV Sedation: Anesthesia used for people who want to be asleep during dental procedures. It is sometimes described as a “light” anesthesia. (See Anesthesia, Local Anesthesia).

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Jacket: Crown for a front tooth, usually made of porcelain.

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Laminate: Thin plastic or porcelain veneer produced in a dental laboratory and then bonded to a tooth.

Lasers: Dental lasers are a family of instruments, some used for surgery, some to cure (harden) restorative tooth materials and enhance tooth bleaching, and others to remove tooth structure to eliminate disease.

Laughing Gas: Nitrous oxide; odorless inhalation agent that produces relative sedation; reduces anxiety and creates a state of relaxation.

Local Anesthesia: Relieves the sensation of pain in a localized area. (See Anesthesia, IV Sedation).

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Malocclusion: “Bad bite” or misalignment of the upper and lower teeth.

Managed Care: Program whereby patient-dentist agreement and dentist reimbursement is administered by a separate, external organization.

Mandible: The lower jaw.

Margin: Interface between a restoration and tooth structure.

Maryland Bridge: A bridge that is bonded to the back of the adjacent teeth; requires minimum tooth reduction.

Maxilla: The upper jaw.

Medicated Filling: A provisional or temporary filling which incorporates a palliative or soothing medication to calm an inflamed tooth nerve.

Molars: The back teeth that are designed for grinding food before swallowing.

Mouth guard: A removable appliance used to protect teeth from injury during athletic activities.

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Nerve (Root) Canal: Dental pulp; the internal chamber of a tooth.

Night Guard: A removable acrylic appliance used to minimize the effects of grinding the teeth (bruxism) or joint problems (TMD), usually worn at night.

Nitrous Oxide: A gas used to reduce patient anxiety, also called “laughing gas”.

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Occlusion: Closure; relationship of the upper and lower teeth upon closure.

Onlay: A gold or porcelain inlay extended to cover the cusps for protection of the tooth.

Oral and Maxillofacial Surgeon: A specialist who deals with the diagnosis and surgical treatment of diseases, injuries, and deformities of the mouth and supporting structures.

Oral Cavity: The mouth.

Oral Hygiene: Process of maintaining cleanliness of the teeth and related structures.

Oral and Maxillofacial Surgery: Surgical procedures on the mouth including extractions, removal of cysts or tumors, and repair of fractured jaws.

Oral Pathologist: Dentist specializing in the study of oral diseases.

Oral Sedation: Any substance taken orally (i.e., a pill or liquid) to reduce anxiety and relax the patient.

Oral Surgery: Surgery of the mouth.

Orthodontics: Dental specialty that treats misalignment of teeth. Treatment usually consists of braces or a retainer.

Overbite: Vertical overlap of the front teeth.

Over Denture: Denture that fits over residual roots or dental implants.

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Palate: The general term that refers to the roof of the mouth.

Palliative Treatment: Non-invasive relief of irritating conditions.

Panorex: A single full mouth x-ray.

Partial Denture: A removable appliance (prosthesis) that replaces some of the teeth in either the upper or lower jaw.

Pathology: Study of disease.

Periapical (PA): Region at the end of the roots of teeth.

Pediatric Dentistry: Dental specialty focusing on treatment of children’s teeth.

Periodontal Disease: The general term for the inflammation or disease affecting the gums.

Periodontal Surgery: Recontouring or esthetic management of diseased gum and supporting tissue.

Periodontics: The treatment of diseases of the gum or bone (supporting structure).

Periodontist: A dentist who specializes in the treatment of gum disease.

Periodontal Chart: Record measuring the depth of gum pockets around the teeth.

Permanent Teeth: (Usually) thirty-two adult teeth in a complete dentition.

Pit: A small defect in the tooth enamel.

Plaque: A sticky substance that forms on the surface of the teeth and harbors bacteria growth and acid formation beneath its surface, causing tooth decay. Plaque buildup can irritate the gums and cause periodontal disease.

Pontic: Replacement tooth mounted on a fixed or removal appliance.

Porcelain Crown: All porcelain restoration covering the portion of tooth above the gum line.

Porcelain Fused to Metal (PRM) Crown: Restoration with metal coping (for strength) covered by porcelain (for appearance).

Porcelain Inlay or Onlay: Tooth-colored restoration made of porcelain, cemented or bonded in place.

Porcelain Veneers: A thin layer of porcelain bonded to a natural tooth to replace lost tooth structure, close spaces, straighten teeth or change color and/or shape.

Post: Thin metal rod inserted into the root of a tooth after root canal therapy; provided retention for a “coping” that replaces lost tooth structure and retains crown.

PPO or PDO: Preferred provider (dental) organization, which a health care (dental) provider may join, offering fee-for-service treatment at reduced fees.

Preventive Services: Dental procedures concerned with the prevention of dental diseases by protective and educational measures. May include exam, cleanings, x-rays and fluoride.

Prophylaxis: The professional cleaning and removal of plaque, stains, and calculus on the teeth.

Prophy Jet: Air polishing for stain removal.

Prosthodontics: The restoration of natural teeth and replacement of missing or lost teeth. Common procedures are crowns, bridges, dentures, and dental implants.

Prosthodontist: A dentist that specializes in the restoration of natural teeth and replacement of teeth. Expertise includes, but is not limited to: crowns, bridges, dentures, dental implants, TMD-jaw joint problems, and oral cancer reconstruction.

Pulp: The nerves, blood vessels and connective tissue inside a tooth.

Pulp Chamber: The opening in the center of the crown of a tooth, which contains the pulp (nerve tissue) and stretches to the tip of the root.

Pulpectomy: Complete removal of the pulp (commonly done in children’s teeth).

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Quadrant: One fourth of the mouth or half of the bottom or top section of the mouth.

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Reimplantation: Insertion and temporary fixation of partially or completely dislodged tooth or teeth, resulting from traumatic injury.

Reline: Acrylic restoration of denture base.

Restoration: Replacement of portion of a damaged tooth.

Retained Root: Partial root structure remaining in jaw after extraction or fracture of a natural tooth.

Retainer: An appliance for maintaining the positions of the teeth and jaws immediately after the completion of orthodontic treatment.

Root: Tooth structure that connects the tooth to the jaw.

Root Canal: A procedure used to save an abscessed tooth in which the pulp chamber is cleaned out, disinfected, and filled with a permanent filling.

Root Planning: Deep cleaning of the teeth to remove hardened plaque below the gum line. This periodontal procedure is usually performed one quadrant at a time.

Root Resection: Removal of a portion of diseased root structure, retaining the remaining natural tooth.

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Saliva: Clear lubricating fluid in the mouth.

Saliva Ejector: Suction tube placed in the mouth to remove saliva.

Salivary Glands: Located under tongue and in cheeks that produce saliva.

Scaling: A treatment for gum disease involving removal of hardened plaque (tartar or calculus) from teeth.

Sealant: Plastic coating applied to grooves of the teeth to prevent decay.

Space Maintainer: Dental device that holds the space lost through premature loss of baby teeth.

Splint: Connection of two or more teeth so they function as a stronger single structure.

Supernumary Tooth: Extra tooth.

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Tartar: Calcified plaque that forms from mineral salts in the saliva and deposits on the teeth.

TMD Temporomandibular Disorders: Problems associated with the temporomandibular joint (TMJ), which connects the lower jaw with the skull. Typically associated with pops and pain in the joint.

Third-Party Provider: Insurance company that pays all or a part of the cost of dental treatment.

Tooth Whitening: A chemical or laser process to lighten the color of teeth.

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UCR: Usual, customary and reasonable fees.

Ultrasonic Cleaning: Cleaning that uses high frequency sound waves to gently remove deposits, such as tartar and stain, from the teeth.

Unerupted Tooth: A tooth that has not pushed through the gum.

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Veneers: Plastic or porcelain facing, which is bonded directly to a tooth to improve its appearance, producing a very natural appearance.

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Whitening: A process, which lightens the color of teeth.

Wisdom Teeth: The third set of molars, the last teeth to come in, usually erupt at age 18-25.

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Zerostomia: Dry mouth or decrease in the production of saliva.

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This information is intended to be general and informational in nature, and is not intended to provide you with legal, medical, tax, financial planning or other professional advice.


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Adjudication: The administrative procedure used to process a claim for service according to the covered benefit.

Administrative Services Only (ASO): An arrangement in which a licensed insurer provides administrative services to an employer’s health benefits plan (such as processing claims), but doesn’t insure the risk of paying benefits to enrollees. In an ASO arrangement, the employer pays for the health benefits.

Allowable Charge: The maximum fee that a health plan will reimburse a provider for a given service.

Alternative Birthing Center: A facility offering a “non-traditional” (“not like a hospital”) setting for giving birth. While alternative birthing centers can range from free-standing centers to special areas within hospitals, birthing centers are generally known for a more comfortable, home-like atmosphere, allow more participation by the father and have more procedural flexibility than commonly found in hospital births.

Ambulatory Care: A general term for care that doesn’t involve admission to an inpatient hospital bed. Visits to a doctor’s office are a type of ambulatory care.

Ambulatory Surgery: Surgical procedures performed that do not require an overnight hospital stay. Procedures can be performed in a hospital or a licensed surgical center. Also called Outpatient Surgery.

Ancillary care: Diagnostic and/or supportive services such as radiology, physical therapy, pharmacy or laboratory work.

Appeals: A process used by a patient or provider to request re-consideration of a previously denied service.

Assignment of benefits: When a covered person authorizes his or her health benefits plan to directly pay a health care provider for covered services. Traditional health insurance pays benefits directly to the covered person.

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Behavioral care services: Assessment and therapeutic services used in the treatment of mental health and substance abuse problems.

Beneficiary: A person who is eligible to receive benefits under a health benefits plan. Sometimes “beneficiary” is used for eligible dependents enrolled under a benefits plan; “beneficiary” can also be used to mean any person eligible for benefits, including both employees and eligible dependents.

Benefits: The portion of the costs of covered services paid by a health plan. For example, if a plan pays the remainder of a doctor’s bill after an office visit co-payment has been made, the amount the plan pays is the “benefit.” Or, if the plan pays 80% of the reasonable and customary cost of covered services, that 80% payment is the “benefit.”

Benefits package: A term informally used to refer to the employer’s benefits plan or to the benefits plan options from which the employee can choose. “Benefits package” highlights the fact a health benefits plan is a compilation of specific benefits.

Brand-name drug: A drug manufactured by a pharmaceutical company which has chosen to patent the drug’s formula and register its brand name.

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Care management: A generic term, which has been used in many different ways. Can mean to take a global approach to medical care from prevention through treatment and recovery.

Carrier: A term historically used for licensed insurance companies, although now is sometimes used to include both licensed insurers and HMOs.

Case management: Coordination of services to help meet a patient’s health care needs, usually when the patient has a condition which requires multiple services from multiple providers. This term is also used to refer to coordination of care during and after a hospital stay.

Certificate of Prior Coverage: Most healthcare insurance programs impose a waiting period for a pre-existing condition for all new, late or reinstated members. A certificate of creditable coverage indicates the length of time you have been continuously covered under a qualifying previous healthcare plan and allows a possible waiver of any waiting period related to a pre-existing condition. Employer-sponsored health insurance companies may require a certificate of creditable coverage in order to waive any pre-existing and elimination period penalty. If you received a letter from your insurance carrier requesting this certification, you are responsible to expedite the requested documents to them.

Charge Amount: The amount billed by a provider for services rendered to a participant.

Chemotherapy: Treatment of malignant disease by chemical or biological antinoeplastic agents.

Claim: A claim is a request for payment under the terms of a health benefits plan.

Claim Status: Claims are Paid, Pended, Denied, or Received-Not-Yet-Processed.

Clinical Practice Guidelines: General procedures and suggestions about what constitutes an acceptable range of practices for particular diseases or conditions. These guidelines are usually developed by a consensus of doctors in a given field, such as radiology or cardiology.

Cognitive service: Diagnostic services a doctor provides during delivery of medical services, consultations or care.

Coinsurance: A traditional method of paying for covered health services in which a portion of covered expenses
are shared by the health benefits plan and the participant. It’s a defined percentage of the covered charges for services rendered. For instance, a health plan may pay 80% of the reasonable and customary cost of covered services, and a participant pays 20%.

Consolidated Omnibus Budget Reconciliation Act (COBRA): A federal statute that requires most employers to offer to covered employees and covered dependents who would otherwise lose health coverage for reasons specified in the statute, the opportunity to purchase the same health benefits coverage that the employer provides to its remaining employees. This continuation of coverage can only last for a maximum specified period of time (usually 18 months for employees and dependents who would otherwise lose coverage due to loss of employment or work hour reduction, or 36 months for dependents who would lose coverage for certain reasons other than employment loss by the employee).

Consultation: A discussion with another health care professional when additional feedback is needed during diagnosis or treatment. Usually, a consultation is by referral from a primary care physician.

Conversion Option: The option to purchase individual coverage by a person who will no longer have access to group health insurance.

Coordination of Benefits: A provision in a contract that applies when a person is covered under more than one group health benefits program. It requires that payment of benefits be coordinated by all programs to eliminate overinsurance or duplication of benefits.

Co-payment (co pay): What the participant pays at the time of service. Co-payments are predetermined fees for physician office visits, prescriptions or hospital services.

Coverage: The benefits that are provided according to the terms of a participant’s specific health benefits plan.

Covered Services: Hospital, medical, and other health care services incurred by the enrollee that are entitled to a payment of benefits under a health benefit contract. The term defines the type and amount of expense that will be considered in the calculation of benefits.

Custodial Care: Care that is provided primarily to meet the personal needs of a patient. The care is not meant to be curative or providing medical treatment

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Date of Service: The date the service was provided to the participant as specified on the claim.

Day Treatment Center: An outpatient facility that is licensed to provide outpatient care and treatment, usually for mental or nervous disorders or substance abuse.

Deductible: The money an individual or family must pay from his or her own funds toward covered medical expenses, usually based on a calendar year. For example, if a plan has a $100 deductible, the deductible is met once the first $100 of the covered medical expenses for that year has been paid. After that, the plan begins to pay toward the cost of covered health care services.

Denied Claim: Claims that are not issued a bank draft/remittance due to a specific reason code.

Dependent: A person eligible for coverage under an employee benefits plan because of that person’s relationship to an employee. Spouses, children and adopted children are often eligible for dependent coverage.

Designated Centers for Specialized Care: Medical centers selected to provide an advanced level of care for a disease or delivery of a specific procedure.

Diagnostic Tests: Tests and procedures ordered by a physician to help diagnose or monitor a patient’s condition or disease. Diagnostic tools include radiology, ultrasound, nuclear medicine, laboratory and pathology services or tests.

Discharge planning: Identifying a patient’s health care needs after discharge from inpatient care.

Disenrollment: Voluntarily terminating one’s participation in a health benefits plan.

Duplicate coverage: When a person has coverage for the same health services under more than one health benefits plan.

Durable medical equipment: Equipment that can withstand repeated use and is primarily and usually used to serve a medical purpose, is generally not useful to a person in the absence of illness or injury, and is appropriate for use in the home.

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Effective Date: The date on which coverage under a health benefits plan begins.

Eligible: Provisions contained in each health benefits plan that specify who qualifies for coverage under that plan.

Emergency: An accident or sudden illness that a person with an average knowledge of medical science believes needs to be treated right away or it could result in loss of life, serious medical complications or permanent disability. Whenever there’s a serious accident or sudden illness, and symptoms are severe and they occur unexpectedly, seek medical help immediately.

Examples of emergency situations include: uncontrolled bleeding, seizure or loss of consciousness, shortness of breath, chest pain or squeezing sensations in the chest, suspected overdose of medication or poisoning, sudden paralysis or slurred speech, severe burns, broken bones or severe pain.

Employee Assistance Program (EAP): An assessment and referral program or a short-term counseling program that is pre-purchased by some employers and is available to their employees, their dependents and household members. Visits to the EAP are separate from your behavioral health care benefits plan with no co-payment required.

Employee Retirement Income Security Act (ERISA): Federal legislation that applies to retirement programs and to employee welfare benefit programs established or maintained by employers and unions.

Experimental Procedures: Experimental, investigational or unproven procedures and treatments.

Explanation of benefits (EOB): A statement provided by the health benefits administrator that explains the benefits provided, the allowable reimbursement amounts, any deductibles, coinsurance or other adjustments taken and the net amount paid. A participant typically receives an explanation of benefits with a claim reimbursement check or as confirmation that a claim has been paid directly to the provider.

Extended care facility (ECF): A medical care institution for patients who require long-term custodial or medical care, especially for chronic disease or a condition requiring prolonged rehabilitation therapy.

Extension of benefits: When a person’s coverage is extended under certain conditions, such as disability, after their group health coverage would otherwise have ended.

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Flexible benefits plan: A type of benefits program that offers employees a menu of benefit options, allowing them to create a benefits package which best suits their individual needs.

Formulary: A list of preferred, commonly prescribed prescription drugs. These drugs are chosen by a team of doctors and pharmacists because of their clinical superiority, safety, ease of use and cost.

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Generic drug: A prescription drug that has the same active-ingredient formula as a brand-name drug. A generic drug is known only by its formula name and its formula is available to any pharmaceutical company. Generic drugs are rated by the Food and Drug Administration (FDA) to be as safe and as effective as brand-name drugs and are typically less costly.

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Home Health Care: Health services rendered in the home to an individual who is confined to the home. Such services are provided to individuals who do not need institutional care, but who need nursing services or therapy, medical supplies and special outpatient services.

Hospice: A health care facility that provides supportive care for the terminally ill.

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In-Network: Refers to the use of providers who participate in a health plan’s provider network. Many benefit plans encourage enrollees to use participating (in-network) providers to reduce the enrollee’s out-of-pocket expense.

Infertility: Term used to describe a condition or the inability to conceive or an inability to carry a pregnancy to a live birth after a year or more of regular sexual relations without the use of contraception.

Infusion Therapy: Treatment accomplished by placing therapeutic agents into the vein, including intravenous feeding. Such therapy also includes enteral nutrition, which is the delivery of nutrients into the gastrointestinal tract by tube.

Inpatient care: Care given to a patient admitted to a hospital, extended care facility, nursing home or other facility.

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Long-term care: The range of services typically provided at skilled nursing, intermediate-care, personal care or eldercare facilities.

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Maintenance medication: Medications that are prescribed for long-term treatment of chronic conditions, such as diabetes, high blood pressure or asthma.

Managed Behavioral Health: This is a program that covers your mental health and substance abuse care needs. In most cases, in-network benefits need to be pre-authorized. The services that may be covered under the benefit plans are: individual therapy, family therapy, group therapy, psychiatric evaluation, psychiatric medication management, intensive outpatient services, inpatient and partial hospitalization. Benefits plans vary by employer (covered services and number of available outpatient visits and inpatient days each year).

Medical Necessity: Medical necessity is a term used to refer to a course of treatment seen as the most helpful for the specific health symptoms you are experiencing. You and your health professional determine the course of treatment jointly. This course of treatment strives to provide you with the best care in the most appropriate setting.

Medicare: Title XVIII of the Social Security Act that provides payment for medical and health services to the population aged 65 and over regardless of income, as well as certain disabled persons and persons with ESRD.

Medicare Part A: Hospital insurance provided by Medicare that can help pay for inpatient hospital care, medically necessary inpatient care in a skilled nursing facility, home health care, hospice care and end-stage renal disease treatment.

Medicare Part B: Medicare-administered medical insurance that helps pay for certain medically necessary practitioner services, outpatient hospital services and supplies not covered by Part A hospital insurance of Medicare coverage. Doctors’ services are covered under Part B even if they’re provided to a member in an inpatient setting. Part B can also pay for some home health services when the beneficiary doesn’t qualify for Part A.

Medigap: A term used to describe health benefits coverage that supplements Medicare coverage.

Member: An individual or dependent that is enrolled in and covered by a managed health care plan. Also called Enrollee or Beneficiary.

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Network: A group of health care providers under contract with a managed care company within a specific geographic area.

Non-Participating Provider: A medical provider who has not contracted with a health plan.

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Occupational Therapy: Treatment to restore a physically disabled person’s ability to perform activities such as walking, eating, drinking, dressing, toileting, and bathing.

Open enrollment: A period when eligible persons can enroll in a health benefits plan.

Out-of-area benefits: Benefits the health plan provides to covered persons for covered services obtained outside of the network service area. The details of such benefits will vary from plan to plan.

Out of Network: The use of health care providers who have not contracted with the health plan to provide services.

Out of Pocket: Co-payments, deductibles or fees paid by participants for health services or prescriptions.

Outpatient care: Any health care service provided to a patient who is not admitted to a facility. Outpatient care may be provided in a doctor’s office, clinic, the patient’s home or hospital outpatient department.

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Partial Day Treatment: A program offered by appropriately licensed facilities that includes either a day or evening treatment program, usually for mental health or substance abuse.

Participant: A person who is eligible to receive health benefits under a health benefits plan. This term may refer to the employee, spouse or other dependents.

Participant ID: The unique identifier associated with a participant.

Participating Provider: A physician, hospital, pharmacy, laboratory or other appropriately licensed facility or provider of health care services or supplies that has entered into an agreement with a managed care entity to provide services or supplies to a patient enrolled in a health benefit plan.

Pended Claim: Claims that require additional information prior to completing the adjudication process due to a specific reason code.

Physical therapy: Rehabilitation concerned with restoration of function and prevention of physical disability following disease, injury or loss of body part.

Pre-Admission Certification/Continued Stay Review (PAC/CSR): The process through which the reviewer evaluates the attending physician’s request for admission to an acute care hospital and length of stay. Medical necessity is determined using established criteria. If PAC/CSR is part of the health benefit plan, the admission or continued stay must be certified for full payment of a claim.

Precertification: The process of obtaining certification from the health plan for routine hospital stays or outpatient
procedures. The process involves reviewing criteria for benefit coverage determination.

Pre-Existing Condition: A health condition (other than a pregnancy) or medical problem that was diagnosed or treated before enrollment in a new health plan or insurance policy.

Preferred Provider Organization (PPO) plan: A network-based, managed care plan that allows the participant to choose any health care provider. However, if care is received from a “preferred” (participating in-network) provider, there are generally higher benefit coverages and lower deductibles.

Prescription drug: A drug that has been approved by the Federal Food and Drug Administration which can only be dispensed according to physician’s prescription order.

Preventive care: Medical and dental services aimed at early detection and intervention.

Primary care: The basic, comprehensive, routine level of health care typically provided by a person’s general or family practitioner, internist or pediatrician.

Primary Care Physician (PCP): A physician, usually a family or general practitioner, internist or pediatrician, who provides a broad range of routine medical services and refers patients to specialists, hospitals and other providers as necessary. Under some benefits plans, a referral by the primary care physician is required to obtain services from other providers. Each covered family member chooses his or her own PCP from the network’s physicians.

Prosthetic Devices: A device that replaces all or a part of the human body because a part of the body is permanently damaged, is absent or is malfunctioning.

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Radiation Therapy: Treatment of disease by radiation, radium, cobalt or high-energy particle sources.

Reason Code: Reason codes provide explanations of claim status for pended and denied claims.

Reasonable and Customary (R&C) and Usual Customary and Reasonable (UCR) Charges / Balance Billing: These are all terms that apply to out of network claims for both your Medical and Dental Plans. If employees go in network then the participating medical and dental providers must accept the insurance carriers contracted fees. However, if you go out of network, then the insurance carrier will only pay the reasonable and customary reimbursement rate for that service. If a member happens to be using a particularly expensive provider that is charging more than the reasonable and customary fees, then the member will be responsible for the coinsurance amount PLUS any charges in excess of what the insurance carrier reimbursed the provider.

Respiratory Therapy: Treatment of illness or disease by introducing dry or moist gases into the lungs.

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Service area: The geographical area covered by a network of health care providers.

Skilled Nursing Facility (SNF): A licensed facility that provides nursing care and related services for patients who do not require hospitalization in an acute care setting.

Specialists: Providers whose practices are limited to treating a specific disease (e.g., oncologists), specific parts of the body (e.g., ear, nose and throat), a specific age group (e.g., pediatrician), or specific procedures (e.g., oral surgery).

Speech Therapy: Treatment to correct a speech impairment that resulted from birth or from disease, injury or prior medical treatment.

Status change: A lifestyle event that may cause a person to modify their health benefits coverage category. Examples include, but are not limited to, the birth of a child, divorce or marriage.

Submission Date: The date the claim was submitted and/or received by the insurance carrier.

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Transitional Benefits/plans: When an employer changes insurance carriers, transition plans enable participants already in treatment to transition to an in-network health provider. It gives the patient and their current provider a specific number of days to contact the insurance carrier in order to discuss the patient’s treatment plan and obtain authorization to continue treatment at the in-network benefit level for a specified period of time, or to transition to a contracted professional.

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Urgent Care: When prompt medical attention is needed in a non-emergency situation, that’s called “urgent” care. Examples of urgent care needs include ear infections, sprains, high fevers, vomiting and urinary tract infections. Urgent situations are not considered to be emergencies.

Usual, Customary or Reasonable (UCR): The amount reimbursed to providers based on the prevailing fees in a specific area.

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This information is intended to be general and informational in nature, and is not intended to provide you with legal, medical, tax, financial planning or other professional advice.

EYE EXAMINATION PROCEDURES

Eyeglass Examinations: The standard examination procedure for a patient who wants to wear eyeglasses includes at least the following:

  • Case history; reason for examination, patient medical and eye history, current medications, etc.
  • Recording of monocular (one eye) and binocular (both eyes) visual acuities at far and near, with and without present correction
  • Pupil responses (Neurological Integrity)
  • External examination findings (Biomicroscopy) Internal examination findings (Ophthalmoscopy)
  • Present prescription (when applicable)
  • Retinoscopy (when applicable)
  • Subjective refraction
  • Phorometry/Binocular testing at far and near
  • Tonometry
  • Diagnosis/Prognosis
  • Specific recommendations

Contact lens examination: Requirements for patients who wish to wear contact lenses include all of the standard eyeglass examination procedures as well as the following:

  • Keratometry
  • Diagnostic lens testing (when applicable)
  • Additional external examination (biomicroscopy) with and without contact lenses
  • Series of follow-up visits to ensure compliance with maintenance and wearing schedules.

Providers generally assess higher charges for contact lens examinations than for eyeglass examinations. Some benefit plans may require members to pay the difference between the usual and customary price for an eyeglass examination and the usual and customary price for a contact lens examination.

Dilation: The enlargement of the pupil diameter, which allows the doctor to observe the internal eye more completely. It is not always part of a provider’s standard examination procedure, but providers may perform dilation if any of the following conditions exist:

  • Diabetes
  • Myopia (nearsightedness) over 6 diopters
  • Hypertension (high blood pressure)
  • Retinal disease
  • Sudden changes in vision
  • Flashes or floaters
  • Family or personal health history that predicts future ocular complications
  • State law requiring dilation

Disease detection: During the course of an examination, an optometrist or ophthalmologist may detect abnormalities in the eye that are symptomatic of certain diseases that require treatment from another health care provider, such as diabetes or hypertension. In this case, the member will be referred to the appropriate medical provider based on their health plan.

Prescription: Prescriptions are often written following an examination to correct one of the following conditions:

  • Myopia: (“nearsightedness”) A condition in which light refracted into the eye focuses at a point in front of the retina. Myopic individuals can see objects clearly at near and have trouble seeing at far. Myopia is correctable with eyeglasses or contact lenses. Myopic correcting lenses are concave, or thinner in the center than on the edge.
  • Hyperopia: (“farsightedness”) A condition in which light refracted into the eye focuses at a point behind the retina. Hyperopic individuals can see objects clearly at far and have trouble seeing at near. Hyperopia is correctable with eyeglasses or contact lenses. Hyperopic correcting lenses are convex, or thicker in the center than on the edge.
  • Presbyopia: The loss of focus ability due to the natural aging process. It is correctable with bifocal or trifocal lenses that reduce the need for the eye to focus when changing from far to near vision.
  • Astigmatism: A condition in which an asymmetric cornea results in different visual irregularities in different parts of the eye. It is correctable with eyeglass lenses that are ground to a different thickness and curvature. Toric soft contact lenses or rigid contact lenses can also correct some cases of astigmatism.

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TYPES OF PROVIDERS

Ophthalmologist: A medical doctor (MD) or osteopath (DO) who specializes in the treatment of the eye and visual system. In addition to providing routine eye care, ophthalmologists can diagnose and treat eye disease using medical or surgical techniques.

Optometrist: An eyecare professional who has completed four years of optometry school after graduating from college. Optometrists specialize in examination, diagnosis, and treatment of conditions of the visual system, including prescribing and fitting eyeglasses and contact lenses. Optometrists are not authorized to use surgical techniques to treat eye disease.

Opticians

  • Dispensing optician: Helps patients with the selection of frames, and also measures, adjusts, and fits eyewear using prescriptions supplied by an optometrist or ophthalmologist.
  • Laboratory optician: Manufactures eyewear using prescriptions supplied by an optometrist or ophthalmologist.
  • Optometric technician: Performs the same duties as a dispensing optician, but has also had two years of formal training or has passed the National Optometric Registration Exam for technicians.

Dispensing location: Optical facilities that have the capability to dispense eyewear. Some dispensing locations have on-site manufacturing capabilities, but the majority of dispensing locations use offsite eyewear manufacturing facilities.

DPA certification: Diagnostic pharmaceutical agent (DPA) certification is granted to optometrists who have demonstrated capability to diagnose eye disease. State licensing agencies serve as the certifying body for DPA certification.

TPA certification: Therapeutic pharmaceutical agent (TPA) certification is granted to optometrists who have demonstrated capability to diagnose and treat eye disease. In addition, TPA certified optometrists can prescribe certain medications to treat eye disease. State licensing agencies serve as the certifying body for TPA certification.

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TYPES OF EYEGLASS LENSES

Single vision lenses: Uncoated, plastic lenses with a single prescription that corrects myopia, hyperopia, or astigmatism.

Standard bifocal lenses: Uncoated, plastic lenses that correct both for distance and near vision in individuals with presbyopia. The top of the lens corrects for distance vision. In the lower part of the lens, there is a visible semicircle ground into the lens that corrects for near vision.

Trifocal lenses: Uncoated, plastic lenses that correct for vision at three distances. The top of the lens corrects for distance vision. In the lower part of the lens, there is a visible semicircle ground into the lens that corrects for near vision. Just above this semicircle is an additional lens segment that corrects for distances of about an arm’s length away.

Lenticular lenses: Designed to treat eye conditions that are more serious than simply myopia, hyperopia, presbyopia, or astigmatism. They are often prescribed after cataract surgery for patients without intraocular implants.

Progressive lenses: Commonly called “no-line bifocals”, progressive lenses are bifocal or trifocal lenses that have an invisible corridor of increasing power that leads from the distance portion of the lens down to the reading portion.

Polycarbonate lenses: Made of a material similar to standard plastic, but are lighter in weight and thinner than uncoated plastic lenses. They offer protection from surface abrasions like scratch resistant coated plastic lenses, and they do not shatter like glass or standard plastic lenses.

Photochromic lenses: Light sensitive glass lenses. The glass contains silver halide crystals that darken when exposed to ultraviolet (UV) light and become clear when removed from the light. In their darkened state, photochromic lenses offer protection from potentially damaging UV rays.

Transition lenses: Light sensitive plastic lenses, which makes them lighter in weight than photochromic glass lenses. They become darker when exposed to ultraviolet light and lighten when removed from the light. Transition lenses resist UV radiation both when light and dark, and the lenses are scratch resistant.

Scratch resistant coated lenses: Offers protection from most surface abrasions. The coating is included as a part of polycarbonate lenses, but available as an option that is applied to the surface of standard plastic lenses after the lenses are ground.

Glass lenses: Generally heavier than plastic lenses and resist scratching better than uncoated plastic lenses.

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TYPES OF CONTACT LENSES

Daily wear contact lenses: Can be soft or rigid contact lenses made of different types of plastic, depending on the specific type of lens. Daily wear lenses are to be worn for periods of less than 24 hours at a time, and should be removed each night before the wearer goes to sleep. Lenses generally need to be replaced annually or biannually.

Extended wear contact lenses: Usually soft contact lenses, but are designed to be worn for 24 hours or more at a time. Some lenses are FDA approved for up to 30 days of continuous wear, but most doctors recommend removing and cleaning the lenses at least weekly. Extended wear lenses have replacement schedules that vary significantly by the specific type of lens and length of continuous wear.

Disposable contact lenses: Soft contact lenses, either daily wear or extended wear, that are replaced on a 7 to 30 day cycle. Wearers generally purchase a supply of disposable lenses that will last six months to one year.

Hard contact lenses: These are made from a rigid plastic resin, polymethylemethacrylate (PMMA). The lenses are more durable and easier to handle than soft contact lenses, but many people may find them uncomfortable. PMMA does not absorb water, and does not allow for the transmission of oxygen through the lens to the eye. Hard contact lenses should be removed daily.

Rigid gas permeable contact lenses: (RGP) These contact lenses are made of a non-absorbent material that is oxygen permeable. RGP lenses are durable and easy to handle like hard contact lenses, but more comfortable to wear, though usually not as comfortable as soft contact lenses. Most RGP lenses are used for daily wear, but some lenses can be worn for extended periods of time.

Medically necessary contact lenses: Following certain surgeries, soft contact lenses are sometimes prescribed to act as a replacement for the front covering of the eye that has been removed or disturbed. These contact lens prescriptions are medically necessary, and are generally addressed differently than elective contact lenses in managed vision care policies. Medically necessary contact lenses can also be prescribed for the treatment of certain eye diseases, including keratonocus.

Toric lenses: Either hard or soft contact lenses used to treat astigmatism, which cannot be corrected with traditional spherical contact lenses.

Tinted contact lenses: Many soft and disposable contact lenses have a visibility tint, usually bluish, that makes them easier to see. This visibility tint makes the lenses easier to handle and easier to find if the wearer drops them. There is generally no additional charge for lenses with a visibility tint. Contact lenses can also be tinted to change or enhance the color of the wearer’s eye. The lenses are generally made with a clear center so that the wearer’s perception of color is not affected. Since these lenses are more complicated to manufacture, they are generally more expensive than clear contact lenses.

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LASER VISION CORRECTION TERMS

Lasik: Laser in-situ keratomileuis (Lasik) is a laser refractive procedure in which a portion of the outermost layer of the eye is temporarily pulled away to allow a laser beam to make direct contact with the stroma of the cornea. The laser beam is used to reshape the cornea so that it focuses light properly into the eye. The outer layer of the eye is then replaced. Recovery time after a Lasik procedure is usually very short, often a matter of hours, and patient satisfaction with the procedure is very high. The procedure is nearly painless, and it can be used to treat myopia, hyperopia, and astigmatism. Lasik was introduced in the mid 1990’s, and is now the most commonly performed laser vision correction procedure.

PRK: Photorefractive keratectomy (PRK) was one of the first laser refractive surgery procedures performed to correct vision defects. In PRK, the outermost layer of the eye is removed, and then a laser beam is used to reshape the cornea. PRK can be used to correct myopia, hyperopia, and astigmatism, and results are fairly predictable. The removal of the outermost layer of the eye can result in significant discomfort, long recovery time, and the need for steroid drops to reduce inflammation in many patients. PRK was introduced in the early 1990’s.

RK: Radial keratotomy (RK) was introduced in the 1980’s as a surgical technique to correct myopia. RK involves surgical scarring of the peripheral cornea to change the curvature of the cornea. Small incisions are made at even intervals around the surface of the eye. As the incisions heal, scar tissue develops and causes the cornea to reflect light at different angles. RK outcomes are often unpredictable and rely heavily on the individual surgeon performing the procedure. It also introduces the possibility for serious eye damage and compromises the integrity of the eye. Since the introduction of the laser refractive procedures, RK has rarely been performed in the United States.

AK: Astigmatic keratotomy (AK) is a variation of RK that corrects astigmatism. In AK, incisions are made in the eye at angles instead of at even intervals. AK, like RK, is rarely performed in the United States due to the significant potential for complications and the introduction of laser refractive procedures.

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This information is intended to be general and informational in nature, and is not intended to provide you with legal, medical, tax, financial planning or other professional advice.


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