Start with your own contract
These are general explanations, not definitions for a specific plan. When your evidence of coverage defines a term differently, the plan document controls.
- Allowed amount
- The amount a plan recognizes for a covered service. In network, this negotiated amount usually becomes the starting point for both the plan payment and your share, even when the dentist's listed charge is higher.
- Annual maximum
- The most the dental plan will pay for covered services during a benefit year. This is not the medical-style out-of-pocket maximum that caps what you pay. Once the dental maximum is exhausted, the plan generally stops paying until the next benefit year.
- Benefit basis
- The dollar amount to which the coverage percentage is applied. It may be the allowed amount, but a downgrade or least-expensive-alternative provision can reduce it.
- Cash price
- A self-pay amount offered outside the insurance claim. It may reflect prompt payment, a package, or an office membership arrangement. Compare what is included before treating it as equivalent to an insured quote.
- Coinsurance
- The percentage of the allowed amount assigned to you after any deductible. If the plan says it pays 80 percent, your coinsurance is commonly the remaining 20 percent, subject to other rules.
- Contractual adjustment
- The difference between an in-network dentist's charge and the plan's allowed amount that the participating office generally agrees not to bill to the patient.
- Coordination of benefits
- The rules used when two dental plans cover the same person. One plan is primary and the other may contribute second, but the combined payment does not simply equal both plans' full stated percentages.
- Deductible
- The amount you pay for covered services before the plan begins paying for categories subject to the deductible. Many plans handle preventive services differently, so the benefit document controls.
- Downgrade or alternate benefit
- A rule that calculates the benefit using a less expensive covered treatment even when you and the dentist choose a different treatment. The plan is pricing its benefit, not necessarily changing the treatment you receive.
- Evidence of coverage
- The plan document that describes covered services, exclusions, limitations, appeals, network rules, and definitions. A short benefit summary is convenient, but the longer contract is more complete.
- Frequency limit
- A rule that pays for a service only a certain number of times or after a stated interval. Common examples involve exams, X-rays, cleanings, and replacement of crowns or dentures.
- In network
- A dentist has a participation agreement with the plan. The agreement commonly sets allowed fees and billing rules. Network status can differ by the exact plan, not just by insurance company.
- Missing-tooth clause
- A plan exclusion or limitation that may affect replacement of a tooth that was already missing before coverage began. It can be important for implants, bridges, and dentures.
- Out of network
- A dentist does not have a participation agreement for that plan. The plan may still pay a benefit, but its recognized fee can be lower than the dentist's charge and the remaining balance may be yours.
- Predetermination
- A pre-treatment estimate produced by the carrier from a proposed treatment plan. It is useful written evidence of expected benefits, but eligibility and remaining benefits are checked again when treatment occurs, so it is not a payment guarantee.
- Procedure code
- A standardized code used to describe a dental service on treatment plans and claims. A code identifies the billed service; it does not prove that the service is covered or clinically necessary in a particular case.
- Replacement interval
- A type of frequency limit stating how long a restoration or appliance must be in service before the plan will pay to replace it. The interval and exceptions vary by contract.
- Waiting period
- A period after coverage begins during which certain categories are not yet eligible for benefits. Preventive, basic, major, and orthodontic services can have different rules.
Put the terms into an estimate
Once you have the allowed amount, deductible remaining, coverage percentage, annual maximum remaining, network status, and any downgrade basis, the detailed calculator can model a patient share. The printable estimate checklist helps you collect those values from the office and carrier.
Sources and evidence notes
The links below support the procedure and insurance explanations. The dollar ranges are this site's rounded planning figures; their construction and limits are explained separately in the methodology.
- Health coverage glossaryHealthCare.gov. Plain-language definitions for allowed amount, deductible, coinsurance, networks, and cost sharing.
- Typical dental plan benefits and limitationsAmerican Dental Association. Background on annual maximums, fee schedules, exclusions, and plan cost-containment rules.
- Pre-authorizations and predeterminationsAmerican Dental Association. Explains why a pre-treatment estimate is useful but is not a guarantee of payment.