Dental Term - Legal Principles & Concepts

• usual, customary, reasonable fee (UCR)

  benefits are percentages of the UCR determined through survey and research of local dentists' fees. For example, 80% of three surface amalgam restorations would be 80% of the regional UCR fee for that procedure.
• table of allowance


  insurance company policy establishes a specific amount for a specific service. The patient is responsible for any difference in fees between the cost of the service and the table of allowance fee.
• fixed fee


  fixed schedule of fees for specific services determines the amount of benefits received. The provider agrees to accept this amount as full cost. Fixed fees are usually federally mandated, for example, Medicaid.
• Health maintenance organization (HMO)


  The provider and patient must belong to the plan that offers specific services to members and a stipulated payment allotment to the provider regardless of the amount of procedures completed; also calledclosed panel dentistry.
• Preferred provider organizations (PPO)


  The employer, group, or organization contracts with the provider for lower-than-usual rates on dental services.
• Exclusive provider organization (EPO)


  The EPO is similar to the PPO program with the exception that the subscriber is offered service fromonlydentists who are members of the provider network.
• Medicare Part A


  hospital care—inpatient services in hospital, skilled-care facilities, hospice, and home health care.
• Medicare Part B


  physician care—doctor service, outpatient care, some preventive care; patients may be responsible for a deductible amount; some doctors accept assigned fees.
• Medicare Part C


  Medicare-Advantage—provides extra health-care coverage with additional patient premium costs; provides benefits under plan A and B, emergency care, and urgent care; some offer vision, dental, and wellness, and may also offer HMO, PPO, and Private Fee for Services (PFFS) plans.
• Medicare Part D


  covers pharmacy costs in two manners: Medicare Prescription Drug Plan (PDP) or Medicare Advantage Plan (HMO or PPO); must have parts A and B. Restorative dentistry and most other dental care is not covered by Medicare, with the exception of some hospital surgical care and some prescription needs.
• Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)


  provides care for dependents of military personnel; usually received in military or public-health facilities. This program is now called TRICARE, but both names are appropriate.
• assignment of insurance benefits


  policyholder's authorization to pay allowable claim benefits to the care provider (dentist). If not signed, the benefits will be sent to the policyholder.
• authorization to release information


  permission from the patient or patient's guardian to release patient record data and treatment record to a specified party.
• beneficiary


  person entitled to receive the policy's payment of claim.
• benefit


  amount paid by insurance company to the policyholder or specified provider of care.
• birthday rule


  standards to determine the primary insurance policy when two or more policies are involved, as with children of parents who each have a different policy or company.
• coordination of benefits


  plan by different insurance companies where both pay on the claim.
• customary fee

  average fee range for procedures completed by the care providers in a given area or geographical section.
• deductible


  specified amount to be paid by the policyholder in an allotted time (calendar year or policy year), which must be paid before benefits from insurance company begin.
• fiscal year


  12-month period set by an agency or company for accounting and scheduling; many banks and government agencies start the year on July 1 and end on June 30th.
• procedural code


  code system constructed to provide a specific number to each treatment or procedure performed; used to file claims and determine benefits.
• superbill


  preprinted form listing procedure numbers and services rendered to the patient.
• manual

  use of ledger books, receipt slips, entry charges, and payments from the patient's records.
• one-write system


  collection of papers arranged in sequential order, one written entry can be recorded for various office records.
• charge slip


  paper form used to show the procedure performed, fees charged, and need for follow-up appointment
• day sheet


  daily record of appointments, services, and business activities of the day; also called a daily journal sheet.
• ledger card


  record-keeping sheet of services, charges, and payments for a person or a family.
• traveler's check


  bank sells agency checks in specified amounts ($10, $20, $50, etc.). The purchaser signs the face of the check once at the time of purchase and again at the time of use.
• voucher


  check with an attached stub indicating payment information, such as a payroll check with hours worked, gross and net pay, deductions, and yearly totals.
• money order


  similar to a check, as it is a written order, but may be issued by stores or business establishments and post offices.
• deposit slip


  form for recording submitted cash and checks, included with monies deposited into the business account.
• blank endorsement


  signature of the payee only; may be cashed by anyone.
• restricted endorsement


  signature of the payee following a restriction line such as "For deposit only"; it can be deposited only in the payee's account.
• third-party endorsement


  signature of the payee following instructions to pay the check amount to a third person, such as “Pay to order of Delta Dental Supply Co.” This type of endorsement is also calledendorsement in fulland is difficult to cash.
• nonsufficient funds (NSF)


  designation for a check written for more money than is present in the account; commonly called "a bounced check."
• defendant


  accused or person named in a lawsuit.
• deposition


  testimony given under oath regarding specific event or occurrence.
• judgment


  final decision by the court.
• litigation


  lawsuit
• plaintiff


  injured person or guardian in a lawsuit; the party who initiates or files a lawsuit.