Glossary of Dental Terms
Dental Insurance Terms
Use this guide to familiarize yourself with the terms that you may find in your dental plan and make the most of your benefits.
Annual Maximum Limit means the maximum dollar amount that Delta Dental New Mexico will pay for Covered Services within a Benefit Period for an Enrolled Person. Any additional cost beyond the Annual Maximum Limit is the responsibility of the Patient.
Approved Fee means the maximum fee that Delta Dental of New Mexico will approve for a Covered Service in a given region or specialty under an applicable Delta Dental Provider Schedule, Non-Participating Provider Schedule, and/or Processing Policies. In all cases, Delta Dental of New Mexico will make the final determination regarding the Approved Fee for a Covered Service.
Balance Billing means a business practice adopted by a Dental Provider to collect the difference between the billed amount set by the Dental Provider and the reimbursement amount of a dental insurer. Note that Delta Dental Providers agree to accept the Approved Fee as payment in full and cannot Balance Bill an Enrolled Person for any difference.
Benefits means the maximum amount that Delta Dental of New Mexico will pay for a Covered Service under the terms and conditions of the Plan. Benefits may be expressed in many ways, such as a dollar amount, number of days, or the number of Services. Some Benefits are generally discussed in an Individual Policy or Group Evidence of Coverage, but are specified in your Summary of Benefits.
Benefit Period means the period of time during which the Deductible, Annual Maximum Limit, or Lifetime Maximum Limit accumulate, and Frequency Limitations apply, as shown in the Summary of Benefits.
Billed Amount means the amount set by a Dental Provider for a Service, based upon the Dental Provider’s desired fee, taxes, costs, overhead, margin, and other factors, that a Dental Provider submits with a Claim and reported as the “Submitted Amount” on an Explanation of Benefits statement.
Claim means a written request submitted to Delta Dental of New Mexico through a Claim Form and with supporting records and information for the reimbursement of Services provided by a Dental Provider. The Claim must include necessary information and documentation, such as treatment details and costs, so that Delta Dental of New Mexico can determine coverage, Medical Necessity & appropriateness, and reimbursement in accordance with the Plan, any participating Dental Provider agreement, and and other applicable requirements. The Dental Provider typically includes their Billed Amount for Services that are set by the Dental Provider and vary from Dental Provider to Dental Provider.
COBRA means the federal Consolidated Omnibus Budget Reconciliation Act of 1986 that permits certain eligible employees and their families to keep their employer-sponsored group health benefits by their group health plan for limited periods of time under certain circumstances such as a voluntary or involuntary job loss, reduction in the hours worked, transition between jobs, death, divorce, and other life events.
Coinsurance means the percentage of the Dental Provider’s approved fee that an Enrolled Person must pay to the Dental Provider after Deductible requirements are met under the Plan. Coinsurance amounts depend upon the selected Plan and specified in the Summary of Benefits. Note that coinsurance amounts paid by a Member pays do not apply towards your Annual Maximum Limit or Lifetime Maximum Limit, however the percentage that Delta Dental of New Mexico pays does.
Copayment or Copay means a fixed amount that an Enrolled Person must pay for certain Services that may or may not count toward Deductible requirements under the Plan and the Summary of Benefits.
Covered Services means Services that are covered and Medically Necessary and appropriate in accordance with the terms and conditions of the Plan and applicable Processing Policies.
Credentialing means the process that Delta Dental of New Mexico uses to ensure that a Dental Provider is properly licensed, trained, and qualified to treat Members and participate in a Delta Dental Provider Network.
Deductible means the amount that an Enrolled Person must pay toward Covered Services before Delta Dental of New Mexico will make any payment for the reimbursement of Covered Services under the Plan. Refer to your Summary of Benefits to determine Deductible amounts.
Delta Dental Provider means a Dental Provider who satisfies Credentialing requirements and entered into an agreement with Delta Dental of New Mexico or any Delta Dental Member Company to participate in a Delta Dental Provider Network and provide Services to Members under certain terms and conditions.
Dental Insurance means the transfer of risk of eligible financial loss and expenses for Covered Services incurred by an Enrolled Person to Delta Dental of New Mexico. Delta Dental of New Mexico assumes the risk of eligible financial loss and expenses for Covered Services in consideration of collected Premium under the terms and conditions of the Plan. Simply stated, as a dental insurer, Delta Dental of New Mexico agrees to reimburse an Enrolled Person for certain amounts of financial losses and eligible expense incurred for Services covered by the Plan during the Term of the Plan.
Dental Provider means a person qualified and licensed to practice dentistry or dental therapy, or dental hygienists or dental hygienists certified in collaborative practice and any service constituting the practice of dentistry under New Mexico or other State’s law, as appropriate.
Dependent means, unless as otherwise defined in this Plan, an individual relative or child of a Subscriber who relies upon the Subscriber, as a spouse, domestic partner, parent, or guardian for financial support, which is the basis for eligibility for benefits under the Plan if enrolled with and accepted and approved by Delta Dental of New Mexico for dental coverage under the Plan.
Designation of Payment means a designation or attestation by a Member to direct the payment of Covered Services to a Non-Participating Dental Provider on the Claim Form under the Plan and Processing Policies. A Non-Participating Dental Provider must cooperate and coordinate with Delta Dental of New Mexico to make the direct payment under a Member’s designation, otherwise payment will be made to the Member. The EOB will indicate whether Delta Dental of New Mexico sent payment to the Member or designated Non-Participating Dental Provider.
Effective Date means the date on which coverage goes into effect for an Enrolled Person after Delta Dental of New Mexico: (1) receives, accepts, and approves the Application; and (2) receives the required Premium.
Eligible Dependent means a Dependent of a Subscriber who meets the eligibility requirements specified in both the application and the Plan.
Eligible Person means a person who is a Subscriber or Dependent who meets the eligibility requirements specified in both the application and the Plan.
Enrolled Dependent means an Eligible Dependent that the Subscriber lists on the application and provided enrollment information, which has been received and approved by Delta Dental of New Mexico for coverage under the Plan and for whom the Subscriber has paid additional Premium.
Enrolled Person means an Eligible Person who: (1) has met the eligibility requirements specified in both the application and the Plan; (2) has been accepted and approved by Delta Dental of New Mexico; and (3) for whom Delta Dental of New Mexico has received Premium. An “Enrolled Person” is synonymous with a “Covered Person”.
Evidence of Coverage (“EOC”) means the detailed agreement that describes terms and conditions of Group Dental Insurance issued by Delta Dental of New Mexico to an Enrolled Persons. The EOC is and should be read as part of the Plan. To the extent that anything set forth in the EOC conflicts with the Summary of Benefits, the Summary of Benefits will control.
Explanation of Benefits (“EOB”) means a paper or electronic document provided by Delta Dental of New Mexico detailing the Services that were reimbursed on the Enrolled Person’s behalf. Note that an EOB is not a bill.
Group means a public or private employer who contracts with Delta Dental of New Mexico to provide dental coverage, on an insured or administrative services basis, as one of the benefits of employment to eligible and enrolled employees. The Group works with Delta Dental of New Mexico to select the plan type, maximums, benefit levels, and Member eligibility.
Fee Schedule means a list of charges for specific Services that is used to reimburse Dental Providers on a fee-for-service basis.
HIPAA means the federal “Health Insurance Portability and Accountability Act of 1996,” intended to improve access to health coverage, limit fraud and abuse, protect personal health information, and control administrative costs. See U.S. Department of Health and Human Services’ web site for more information at http://aspe.os.dhhs.gove/admnsimp/.
Lifetime Maximum Limit means the maximum dollar amount that Delta Dental of New Mexico will pay for Covered Services within the lifetime for an Enrolled Person.
Member means a Subscriber and any Dependents that are enrolled under a Dental Plan issued by Delta Dental of New Mexico on a individual or Group insurance or administrative services basis.
Non-Participating Provider means a Dental Provider who has not entered into a formal agreement with Delta Dental of New Mexico or any Delta Dental Member Company to participate in any Delta Dental Provider Network. Non-Participating Providers are not subject to the Delta Dental Approved Fees as payment in full and may Balance Bill a Member for the full Billed Amount set by the Non-Participating Provider.
Policy means the detailed agreement that describes terms and conditions of Individual Dental Insurance issued by Delta Dental of New Mexico to Enrolled Persons. The Policy is and should be read as part of the Plan. To the extent that anything set forth in the Policy conflicts with the Summary of Benefits, the Summary of Benefits controls.
Premium means the annual or monthly amount paid by the Subscriber to Delta Dental of New Mexico for dental coverage under the Plan.
Prior Authorization means a process performed by Delta Dental of New Mexico to determine whether a proposed Service is a Covered Service, Medically Necessary and appropriate, and an estimation of a Member’s out-of-pocket costs under the Plan. A Prior Authorization is voluntarily requested by the Member or the Dental Provider and is the same as a Pre-Treatment Estimate.
Processing Policies means policies and procedures that Delta Dental of New Mexico uses to process Prior Authorizations, Claims, and other payments or services under the Plan that may be amended from time-to-time by Delta Dental of New Mexico.
Service or Services means dental services, supplies, devices, procedure, equipment, or treatment rendered by a Dental Provider considered to be safe, effective, and Medically Necessary and appropriate for the diagnosis or treatment of an existing dental condition. Covered Services do not include experimental, investigational, or elective Services as determined by Delta Dental of New Mexico in accordance with applicable law.
Summary of Benefits means a document that outlines the specific benefits, limitations, exclusions, cost-sharing requirements, Annual Maximum Limit, Lifetime Maximum Limit, Delta Dental Provider Networks, and other terms and conditions of coverage of Services under the Plan. The Summary of Benefits shows specifically what the Plan covers or does not cover, and what a Member’s share of costs will be for Services.
Utilization Review means a formal process designed to monitor the use of or evaluate the Medical Necessity and appropriateness, efficacy, or efficiency of Services. Utilization Review assists Delta Dental of New Mexico in making coverage determinations, control costs, and monitor quality of care. Utilization Review is also referred to as clinical review.
Dental Professionals
In maintaining oral health and wellness, Delta Dental of New Mexico Members may require Services from Dental Providers with various types of expertise and specialties. The following information can help Members better understand the different types of Dental Providers.
Dental Provider means a person qualified and licensed to practice dentistry or dental therapy, or dental hygienists or dental hygienists certified in collaborative practice and any service constituting the practice of dentistry under New Mexico or other State’s law, as appropriate.
Dental Specialist means a Dental Provider who has received postgraduate training in one of the Dental Specialties recognized by the National Commission on Recognition of Dental Specialties and Certifying Boards:
- Dental Anesthesiology
- Dental Public Health
- Endodontics.
- Oral and Maxillofacial Pathology;
- Oral and Maxillofacial Radiology;
- Oral and Maxillofacial Surgery
- Oral Medicine
- Orofacial Pain
- Orthodontics and Dentofacial Orthopedics;
- Pediatric Dentistry.
- Periodontics; or
- Prosthodontics.
Endodontist means a Dental Specialist who focuses on the prevention, diagnosis and treatment of dental pulp and tissues surrounding the roots and nerve of a tooth. They complete advanced education and training to perform Services such as root canals, endodontic surgery, and other special procedures to save teeth after traumatic dental injuries.
General Dentist means a Dental Provider who has received either a Doctor of Dental Surgery (DDS) or a Doctor of Dental Medicine (DDM) from an accredited dental school to practice as a General Dentist and provide Services such as fillings, crowns, and implants.
Oral and Maxillofacial Surgeon means a Dental Specialist who has focuses on reconstructive surgery of the face, oral cavity, head and neck, mouth, and jaws. They completed advanced education and training in surgery, anesthesia, and esthetics to treat diseases, injuries, defects, and appearance aspects to the mouth, teeth, jaws, and face. They perform Services such as wisdom teeth extraction, dental implant surgery, facial reconstruction, and oral cancer treatment.
Orthodontist means a Dental Specialist who focuses upon the treatment of teeth and jaw alignment. They complete advanced education and training to perform Services that use a range of appliances to correct orthodontic issues such as braces or aligners.
Pediatric Dentist means a Dental Specialist who focuses upon the prevention, diagnoses and treatment of dental conditions for infants, children, and teens. They complete advanced education and training to perform Services such as infant oral health exams, caries risk assessments, preventative dental care, habit counseling, tooth repair and alignment, dental injuries,
Periodontist means a Dental Specialist who focuses on the diagnosis and treatment of periodontal or gum disease and the placement of dental implants. They complete advanced education and training to perform Services such as scaling, root planning, root surface debridement, and oral inflammation treatment.
Prosthodontist means a Dental Specialist who focuses on making replacements for missing or damaged teeth, TMJ pain or disfunction, mouth or facial pain, and obstructive sleep apnea. They complete advanced education and training to perform Services such as making crowns, bridges, dentures, and other restorative treatments.
Common Dental Services
Here’s a Guide to gain a general understanding of common Dental Services.
Abutment: A natural tooth or implanted tooth substitute used to support a removable partial denture or bridge work.
Acid Etching: A process that prepares tooth surface for bonding to fillings or sealants by toughening enamel with a weak acid solution.
Alveoloplasty: A surgical procedure that reshapes the jawbone.
Anesthesia: Medication administered to an individual prior to a procedure with the purpose of dulling pain or sedating the individual. Dentists most commonly use local anesthesia to numb the area where pain is likely to occur without changing the awareness of the individual undergoing the procedure.
Apicoectomy: A minor surgical procedure that removes the apex, or top, of the root of a tooth.
Band: A metal ring cemented around a tooth as part of orthodontic treatment. Bands can hold various attachments used to assist with tooth movement and alignment.
Basic Cleaning: A routine professional teeth cleaning to remove plaque build-up, tarter, and stains. This is a regularly scheduled preventative treatment for individuals with healthy gum tissue.
Biopsy: The process of removing tissue for histologic evaluation, an important tool in the accurate diagnosis of cancer and other diseases.
Bleaching: A cosmetic procedure that whitens teeth with a bleaching solution.
Bonding: A procedure in which a tooth-colored plastic material is applied with a special light, and ultimately “bonds” the material to the tooth to improve a person’s smile.
Bridge: An appliance that replaces missing teeth by securely attaching an artificial tooth to the natural teeth. This is also known as a fixed partial denture.
Cement Base: Material sometimes used to replace a missing tooth structure.
Composite: A filling material used to repair teeth. The most common type of filling.
Crown: A cover that is put over a tooth to help restore the tooth's normal shape, size, and function. These are typically applied when individuals have a cavity too large for filling, a cracked or weakened tooth, or want to conceal a discolored or poorly shaped tooth.
Crown Lengthening: A surgical procedure that recontours gum tissue, and sometimes bone, to expose more of the tooth for a crown.
Dental Prophylaxis: A scaling and polishing procedure used to remove plaque and stains.
Dental Prosthesis: An artificial device that replaces missing teeth.
Debridement: A procedure for removing calculus (tartar) and plaque.
Excision: The surgical removal of bone or tissue.
Extraction: The act of removing a tooth or portions of a tooth.
Simple Extraction: This type of extraction does not require sectioning of the tooth or any other elaborate procedures for removal.
Filling: The act of restoring a lost tooth structure using materials such as metal, plastic, alloy, or porcelain.
Amalgam: A single surface silver filling.
Composite: A single surface filling made of tooth-colored plastic. Usually performed on a tooth in the front of the mouth.
Fluoride Varnish: A liquid containing fluoride that is painted onto the teeth and hardens. It is used to prevent or reduce the risk of cavities.
Full-Mouth X-Ray: The combination of 14 or more periapical and bitewing films of the back teeth that reveals all of the teeth including the crowns, roots, and alveolar bone.
Gingivectomy: A surgical procedure for removing gingiva (gum tissue) in order to restore gum health.
Gingivoplasty: A surgical procedure for reshaping gingiva (gum tissue).
Graft: A piece of tissue or alloplastic material placed in contact with tissue in order to repair a deficiency.
Immediate Denture: A prosthesis constructed and placed immediately after the removal of natural teeth.
Implant: A device placed within or on the bone of the jaw or skull to support either a crown, bridge, denture, facial prosthesis, or to act as an orthodontic anchor.
Mouthguard: A removable plastic device worn over teeth and gums to protect from damage during sports.
Nightguard: A removable device worn over teeth at night to protect from damage due to clenching or bruxism.
Operculectomy: A procedure that removes the flap of tissue over an unerupted or partially erupted tooth.
Overdenture: A removable prosthetic device that covers and rests on one or more natural teeth, the roots of natural teeth, and/or dental implants.
Partial Denture: A prosthetic device used to replace missing teeth.
Preventative Dentistry: Procedures and services administered to prevent oral diseases.
Prophylaxis: A dental cleaning that consists of the removal of plaque, stains, and calculus by scaling and polishing.
Pulpectomy: A procedure that removes diseased pulp tissue.
Radiograph: An image produced by projecting radiation. Also called an X-ray.
Reline: A procedure used to resurface the side of a denture that is not in contact with the soft tissue of the mouth to ensure a secure fit.
Removable Partial Denture (Removable Bridge): A prosthetic replacement used to replace missing teeth. This device can be removed by the individual.
Retainer: A removable device worn in the mouth to prevent teeth from shifting. These devices can be fixed or removable.
Root Planing: A procedure performed on tooth roots to remove dentin, bacteria, calculus, and diseased surfaces.
Scaling: The removal of plaque, calculus, and staining from teeth.
Sealants: Plastic resin placed on the biting surfaces of molars in order to prevent bacteria from attacking the enamel.
Suture: A stitch used to repair an incision or wound.
Temporary Removable Denture: An interim prosthesis designed to be used for a limited period of time.
Veneer: Thin coverings placed over the front part of teeth made to look like natural teeth.
Dental Condition Terms
Here is a summary of Dental Condition Terms to help you if an oral health problem arises and you are considering seeking Dental Services.
Abscess: Localized buildup of pus in an area of infection, usually around the tooth or in the gums, that can ultimately destroy oral tissue.
Abrasion: Tooth wear caused by forces other than chewing such as improper brushing or holding objects between the teeth.
Avulsion: When a tooth is knocked out of its socket due to trauma.
Bone Loss: A decrease in the amount of bone that supports a tooth or implant.
Bruxism: An unconscious habit of grinding or clenching the teeth.
Calculus: A hard deposit of mineralized material sticking to the crowns and/or roots of teeth. This substance cannot be brushed off and is removed during a professional cleaning.
Caries: Tooth decay. Tooth surfaces are slowly destroyed by acid-producing bacteria.
Cavity: An area of the tooth that is damaged by caries, abrasion, or erosion.
Cleft Palate: A birth defect that occurs when the tissues that make up the roof of the mouth do not join together completely.
Decay: The decomposition of the tooth structure.
Dry Mouth: A condition caused by lack of saliva and moisture in the mouth. If untreated, it can lead to increased levels of tooth decay and infections.
Dry Socket: Severe pain inside and around the tooth socket which can occur one to three days after a tooth extraction. This issue usually requires post-operative care.
Erosion: The wearing down of tooth structure, caused by chemicals and acid.
Fracture: The breaking of a tooth.
Gingivitis: Inflammation of gingival tissue.
Impacted Tooth: A partially erupted tooth positioned against another tooth, bone, or soft tissue, making complete eruption unlikely.
Lesion: An area of diseased tissue.
Malocclusion: Improper alignment of the upper and lower teeth.
Peri-implantitis: An infection that develops around an implant which can lead to bone loss.
Periodontal Abscess: An infection of the gum pocket that can destroy soft and hard tissues.
Periodontitis: The inflammation and loss of the connective tissue of the supporting structure of teeth.
Plaque: A soft and sticky substance that builds up on teeth due to bacteria buildup.
Pulpitis: Inflammation of the dental pulp.
Recession: When the gums pull away from the teeth, often exposing the root.