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A
Abscess
A swelling or bump, built up in the tissue of the body, filled with pus that is usually caused by an infection. An abscess might need to be drained, or treated with antibiotics and can be identified by pain swelling or redness.
Abutment Supported (Implant)
Characteristic of a crown or other appliance that is placed on a support (abutment) directly over an implant.
Acupuncture
A form of Chinese medicine; very thin needles are placed into the skin at certain points on the body to improve health and well-being, relieve pain or treat illnesses.
Adenoidectomy
Surgery to remove the adenoids, which are glands located in the back of the nose near the throat.
Affordable Care Act (ACA)
The health reform law enacted in 2010. (The formal name is the Patient Protection and Affordable Care Act - PPACA.)
Allowed Amount
The maximum amount that an insurer will consider paying for a service, including any amount that the patient will be responsible for paying. For in-network providers, the allowed amount is based on the contracts with the providers. For out-of-network providers, the allowed amount may be:
• the same as for in-network providers,
• based on a percentage of the amount that Medicare would pay for the same services, or
• Usual, Customary and Reasonable (UCR) charges, an amount that your plan determines is reasonable for that service in your local area.
Alveoplasty
The surgical procedure to prepare the alveolar ridge (jaw bone where the teeth are located) to receive a prosthetic appliance, or complete or partial denture. The procedure involves removing bone and soft tissue to facilitate placement of the appliance or denture, after the teeth have been removed.
Amniocentesis
a pre-natal test that examines a small amount of fluid from the uterus, which may be used to identify certain birth defects in a developing baby (fetus).
Anesthetic (Local)
A drug that a dental provider gives a patient to numb part of the mouth for a short time, which helps prevent pain in the area during dental procedures.
Annual Maximum
A provision included in the majority of dental plans, which places a total dollar cap (maximum) on the amount of benefits that are paid out to an insured during a single plan year. Once the plan's maximum (e.g., $1,000 or $1,500) is reached, the plan will not make any payments until the first day of the next plan year.
Apexification
The techniques that are used to help close the root apex (tip) of a permanent tooth. This is performed when the tooth has experienced extensive decay or trauma and the root has not completely formed (closed). It allows other services to be performed on the tooth to help retain the tooth in the mouth.
Apicioectomy
The surgical removal of the very tip of the root of a tooth. This is performed on teeth that have experienced a root canal, where the patient still has some sensitivity in the area. During this procedure, the tip of the root is removed, and any areas of infection around the root tip are cleaned.
Appendectomy
Surgery to remove an inflamed or infected appendix (appendicitis). Different methods for removing the appendix exist. In an open appendectomy, a cut is made in the lower right abdomen, and the appendix is pulled out through this incision. In a laparoscopic appendectomy (minimally invasive technique), tiny cuts (incisions) are made in the abdomen and a small camera is inserted through the incisions into the abdomen to help guide the removal of the appendix .
Appliance (Dental/Prosthetic Appliance)
A device placed in the mouth to serve a number of functions, such as replacing and/or stabilizing teeth.
Approval Number
A number issued by your insurer authorizing the dental insurance company to pay for your care and also notifying the provider that the service is eligible. You may need to obtain an approval number from your insurer before you see a particular dentist or receive a particular dental service in order for your insurer to pay for that visit and/or service. Your dentist’s office staff might be able to help you obtain the approval number from your insurer.
Arthroscopy
a procedure that can visually examine a joint, such as the knee, hip, wrist or shoulder. The physician inserts a rigid or flexible tube with a tiny camera, called an arthroscope, under the skin to diagnose and/or repair joint problems.
Asthma
A chronic lung disease that inflames and narrows the airways in the lungs. Asthma causes recurring periods of wheezing, chest tightness, shortness of breath, and coughing, which can make it difficult to breathe.
Advance directive
A legal document that tells doctors what kind of healthcare a patient wants. Advance directives are prepared in advance and used only when patients are unable to communicate their healthcare wishes, either because of illness or injury.
B
Bonding
The process of attaching a tooth-colored material (plastic) to a tooth by a dentist to fix a decayed, chipped, broken or discolored tooth. A bonding agent causes the tooth surface to become more porous, allowing the restorative material to attach to these porous areas. It is an alternative to metal fillings. Bonding can usually be done in one dentist visit.
Bone Scan
an imaging test that uses a radioactive “tracer” to detect changes in the bone, which may indicate bone injury or disease.
Breast Cancer
Cancer that forms in tissues of the breast.
Breast Reduction
Surgery to reduce the size and reshape the breast, also known as reduction mammoplasty.
Bridge
A device that closes the gap created by one or more missing teeth. A bridge is created by inserting a false tooth (pontic) in the gap supported by crowns placed on the teeth that are on either side of the pontic. (They are also known as abutment teeth.) The bridge includes all of these parts. Bridges can be used to replace one or more missing teeth in the same arch, and are fixed in the mouth.
Balance Billing
A type of healthcare billing that occurs when an out-of-network provider bills a plan member for the difference between the out-of-network provider's charge and the amount paid by a member's benefit plan for the out-of-network service, and this difference exceeds the member’s defined liability from the plan. For example, if the defined out-of-pocket cost for the member was 20 percent of the provider’s charge and the member pays more than 20 percent—not due to a deductible application—that is a balance bill. This situation happens when a provider does not participate in a member's provider network.
Behavior Management
a process that uses techniques to gain the cooperation and trust of fearful patients, usually children, during dental visits.
Billed Charge
The amount billed by your provider for services you have received. If you use a provider in your plan’s network, the billed charge usually is submitted directly to the insurer and is reduced by the claim payment system to the allowed amount, or contracted rate negotiated by your insurer and the network provider. But, if you use providers outside your network, you will generally have to pay the full difference between your insurer’s allowed amount and the amount that your provider charges that exceeds the allowed amount, unless you and your provider agree otherwise.
Biopsy
A procedure to remove a small sample of body tissue or fluid to be examined for presence of disease. Biopsies can be done surgically or a needle can be used to obtain the tissue sample
Bleaching
The process of whitening teeth. A number of bleaching methods are available. The most common method involves using a strong bleaching agent, which is placed on the teeth, and a special light that helps the bleaching material lighten the teeth.
C
Cancer screening
This involves looking for cancer before a person has any symptoms. Screening tests can help find cancer at an early stage, before symptoms appear. When abnormal tissue or cancer is found early, it may be easier to treat or cure. Getting screening tests regularly may find breast, cervical, and colorectal (colon) cancers early, when treatment is likely to work best.
Carpal Tunnel Syndrome
Pain, tingling and other symptoms caused by pinching of the median nerve that runs from the arm to the hand passing through a small space in the wrist called the “carpal tunnel.” In carpaltunnel surgery, ligaments are cut to relieve pressure on the median nerve.
Cast (Diagnostic Cast)
A model of a patient’s teeth (usually upper and lower) that is used to help the dentist study the teeth and plan treatment when the patient is not available.
Cast Restorations
A restoration of a tooth, made in a laboratory setting. Gold or ceramic crowns, inlays and onlays are all types of cast restorations. Because of the process required to shape the materials into cast restorations, the process cannot be done in the mouth, so a cast (or model) of the patient’s mouth is used instead.
Cataract Surgery
Is performed to remove cataracts, which are painless, cloudy areas in the lens of the eye that can interfere with vision.
CDT or Current Dental Terminology
Current Dental Terminology (CDT) codes are numbers assigned to dental services and procedures. These codes help support accurate recording and reporting of dental treatment and are part of a uniform system designed and maintained by the American Dental Association (ADA). CDT codes have a consistent format and each is unique. Every code number has a written description of the specific dental service or procedure. You will see CDT code(s) on your Explanation of Benefits form (EOB), or you can ask your dental provider for the CDT code for a procedure or service you will undergo or have already received. CDT® is a registered trademark of the ADA.
Cesarean Section
(also called a C-section); a procedure whereby the baby is delivered through an incision in the mother's abdomen.
Chemotherapy
A treatment that uses drugs to kill cancer cells or prevent them from multiplying.
Chiropractic
A therapeutic system based on the principle that many disorders, especially those of the nervous system, can be treated through hands-on manipulation of the spinal column.
Cholecystectomy
Surgery to remove an inflamed or infected gallbladder. The gallbladder is an organ that stores bile, which is made in the liver. Bile aids in the digestion of fatty foods.
Chorionic Villus Sampling
A pre-natal test that looks for potential genetic disorders in cases where certain risk factors are present, such as the mother’s age or family history.
Chronic Obstructive Pulmonary Disease
A chronic inflammatory lung disease that causes obstructed airflow from the lungs. Symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing. Emphysema and chronic bronchitis are the two most common conditions that contribute to COPD. COPD is not simply a "smoker's cough" but an under-diagnosed, life-threatening lung disease that is not fully reversible.
Chronic Sinusitis
A condition in which the cavities around the nasal passages (sinuses) become swollen for at least 12 weeks, despite attempts to treat them. This condition interferes with drainage and causes mucus buildup. Breathing through your nose might be difficult. The area around your eyes and face might feel swollen, and you might have facial pain or tenderness.
Claim
A detailed bill that your provider (your doctor, dentist or other care provider) sends to your plan administrator. This bill shows exactly what services you received and the charges for those services.
Class of Service
Category into which dental plans usually characterize the type of dental care you receive. The four typical classes of service depend on whether the treatment is considered to be diagnostic and preventive, basic restorative or major and complex. A separate class applies to orthodontic procedures when covered by the plan. See Dental Plans.
Cleaning
The removal of plaque and tartar from the visible surfaces of the teeth to help prevent cavities, gingivitis and gum disease. Usually tartar and plaque are removed from the crown portion of the tooth.
COBRA (Consolidated Omnibus Budget Reconciliation Act)
A federal law that lets some people who lose their group health/dental coverage stay on their plan for a limited time, but only if the people pay for the entire cost of the plan themselves. Such people may also have to pay an administrative fee of up to 2 percent. For example, if you lose your job, you might be able to keep your health plan for a while longer by paying the premium to your employer. If your employer paid part of your premium when you were an employee, you may now be required to pay your employer’s share of the premium in addition to the premium you paid as an employee, plus a 2 percent administrative fee.
Co-insurance
A cost-sharing feature of many health and dental plans. It requires a member to pay out- of- pocket a prescribed portion of the cost of covered expenses. The defined co-insurance that a member must pay out- of pocket is based upon his or her plan design. Co-insurance is established as a predetermined percentage of the allowed amount for covered services. If your plan has a deductible, you’ll pay that amount first, and then the co-insurance will be applied to the remaining allowed amount.
Colonoscopy
A visual exam of the large intestine (rectum and colon) performed with a flexible fiberoptic scope. Colonoscopies can be performed as a screening test for colon cancer, and may be used to diagnose and treat other conditions.
Commercial Health and Dental Insurance Data
Commercial health and dental insurance data, which are the type in the FAIR Health database, are based on charge amounts billed by healthcare providers and allowed amounts negotiated between insurers and providers, as reported by health plans and other healthcare payors in the private insurance system. FAIR Health uses these data to develop medical and dental cost estimates that reflect the fees that healthcare providers bill and insurers allow in different geographic areas. Cost estimates based on FAIR Health data are different from fees established by Medicare, a federal health insurance program that covers individuals ages 65 and older, as well as individuals with end-stage renal disease and certain persons with disabilities.
Cone Beam Images
A medical computer X-ray that is increasingly being used by dentists in treatment planning and diagnosis for dental implants.
Consultation
An evaluation by a medical professional who is not treating the patient to provide information on the presence of disease, compromised function and potential treatment options.
Consultation (Dental)
An evaluation by a dental professional, requested by the treating dentist, to provide information on the presence of disease, compromised function and potential treatment options.
Contracted Rates
The amounts that dental insurance companies will pay to dental providers in their networks for services. These rates are negotiated and established in the insurers’ contracts with in-network providers.
Coordination of Benefits
The process of reconciling healthcare charges when an individual is covered by more than one health insurance plan or policy. For example, if a child is insured through both parents’ employers’ plans, one insurer is generally considered the primary insurer and pays first, and the insurer considered secondary reimburses after the primary plan pays. The secondary insurer’s reimbursement, if any, takes into consideration any outstanding dollar amounts for covered services received up to the allowed amount. In any case, the secondary plan will never pay more than they would have paid had they been primary.
Co-pay
A form of cost sharing in a health or dental insurance plan that requires the member to pay a fixed dollar amount for each visit to a provider or for a specific service. This fee is pre-set; it will be specified in your insurance policy and also may be listed on your insurance card.
Cost-Sharing
A requirement that insured patients pay a portion of their medical or dental costs, either as a deductible, a flat dollar co-pay or co-insurance (i.e., a percentage of the total paid claim for a covered benefit or service).
Covered Services
The services, procedures, prescription drugs and other healthcare services that your plan may pay for. Keep in mind that not all services may be covered by your plan. If a service is covered, you may still need to pay a co-payment or co-insurance, or request pre-authorization. Your policy should contain a detailed list of what is and is not covered.
CPT Modifier
A code that is used to provide additional information on a procedure or service. For example, there are modifiers that indicate that a procedure is being repeated or that multiple surgeries were performed at the same time. They can also indicate that the service is more or less complex than normal. The modifier can affect how much plan will pay the provider.
CPT® or Current Procedural Terminology®
CPT® is a registered trademark of the American Medical Association (“AMA”). Current Procedural Terminology (CPT) codes are numbers assigned to services and procedures performed for patients by medical practitioners. The codes are part of a uniform system maintained by the American Medical Association (AMA) and used by medical providers, facilities and insurers. Each code number is unique and refers to a written description of a specific medical service or procedure. CPT codes are often used on medical bills to identify the charge for each service and procedure billed by a provider to you and/or your insurer. Most CPT codes are very specific in nature. For example, the CPT code for a fifteen-minute office visit is different from the CPT code for a thirty-minute office visit.
You will see a CPT code on your Explanation of Benefits form (EOB). You can also ask your healthcare provider for the CPT code for a procedure or service you will undergo, or have already received.
You will see a CPT code on your Explanation of Benefits form (EOB). You can also ask your healthcare provider for the CPT code for a procedure or service you will undergo, or have already received.
Crowns (Caps)
A type of dental restoration made from either metal or ceramic material, which completely encircles a tooth or dental implant. Restorative crowns are often needed when a large portion of the tooth is destroyed by decay or injury and a standard filling would not restore the tooth to proper function. Crowns can also be provided for cosmetic reasons, not based upon decay or trauma, but rather appearance. These cosmetic crowns may not be covered by a dental plan. Prosthetic crowns also are used to help replace missing teeth by providing support for a bridge or partial denture. When these prosthetic crowns are placed on an implant, they are called implant crowns. Crowns are usually made in a laboratory and are attached to the tooth using dental cement.
Cast restorations
Crowns (caps) are a type of dental restoration made from either metal or ceramic material which completely encircles a tooth or dental implant. Crowns are often needed when a large portion of the tooth is destroyed by decay or injury. These restorations are usually fabricated using indirect methods – not on you while you sit in the dental chair - and are bonded to the tooth using dental cement. Crowns are often used to improve the strength or appearance of teeth.
Cast Restorations are dental restorations that use an indirect method (not done in the mouth) of fabrication for tooth restoration. This indirect method usually involves a dental laboratory to fabricate the restoration because these fabrication procedures require intense heat for casting metal (gold or titanium) or firing porcelain which would not be possible to complete inside the mouth. Restorations such as gold or ceramic crowns, inlays and onlays are cast restorations.
Cast Restorations are dental restorations that use an indirect method (not done in the mouth) of fabrication for tooth restoration. This indirect method usually involves a dental laboratory to fabricate the restoration because these fabrication procedures require intense heat for casting metal (gold or titanium) or firing porcelain which would not be possible to complete inside the mouth. Restorations such as gold or ceramic crowns, inlays and onlays are cast restorations.
CT Scan
Sometimes called a CAT scan; x-ray technology is used to provide detailed pictures of the inside of the body. A CT scan generates a clearer image than a regular x-ray.
Culture
A laboratory test that examines a sample of blood, urine, skin or other tissue to look for potential causes of infection or disease
Cystoscopy
A visual exam of the urinary tract performed with a rigid scope which enables the physician to look into the urethra and examine the bladder.
D
Durable Medical Equipment (DME)
Any equipment that provides therapeutic benefits to a patient in need because of certain medical conditions and/or illnesses. DME consists of items which: (a) are primarily and customarily used to serve a medical purpose; (b) are not useful to a person in the absence of illness or injury; (c) are ordered or prescribed by a physician; (d) are reusable; (e) can stand repeated use, and (f) are appropriate for use in the home. Wheelchairs (manual and electric), canes, crutches, walkers, pressure mattresses, hospital beds, traction equipment, nebulizers, bili lights, kidney machines, ventilators and oxygen tanks are examples of durable medical equipment.
Deductible
A fixed-dollar amount of medical or dental costs that you must pay before your insurer will consider payment for a covered service you receive. In most cases, you must pay the deductible amount each calendar/plan year. Many insurance plans have both per individual and per family deductibles. The per family deductible helps to limit the number of deductibles a family will pay in order to have all covered members of the family eligible for claim payments.
Dental Filling (Dental Restoration)
A process that involves repairing a tooth by removing the part of the tooth that is diseased (decayed) or injured. After the diseased or injured part of the tooth is removed, it is replaced with a material that helps restore the tooth’s shape and function. Fillings are usually made of amalgam (silver color) or a composite (white or natural tooth color) and are performed directly in the mouth in the dental office.
Dental Health Maintenance Organization (DHMO)
In a DHMO, just like a medical HMO, you receive all your care from providers in your plan’s network. When you join a DHMO, you select a primary care dentist who coordinates your care, and who refers you to specialists if needed. When you need care, you must visit your primary care dentist first. DHMOs often do not have an annual dollar maximum on coverage.
Dental Indemnity Plan
With a dental indemnity plan, you can choose any dentist you want, and you don’t need a referral to visit a specialist. There is no network of providers in this type of plan. You will generally be responsible for a deductible and co-insurance for services. Most indemnity plans also have an annual benefit maximum. And, you may need your plan’s approval to get some services covered.
Dental Insurance Policy
A contract between you and your insurer that defines what dental services are covered, when and how they will be paid for and any other requirements that must be met so that the dental services will be covered as long as your premium is paid. Having a dental insurance policy does not mean that your insurer will pay for every dental service you receive. It is important for you to know which services are covered by your policy and any requirements that you need to meet in order to have the service covered. You will generally be responsible for paying for any services you receive that are not covered by your policy.
Dental Preferred Provider Organization (DPPO)
In a DPPO, just like a medical PPO, you have the choice of using providers inside or outside your plan’s network. You don’t need to choose a primary dentist, or get referrals to see specialists. But, if you do go out-of-network, your costs will usually be higher because those providers have not agreed to accept the amount your plan is willing to pay. You may not have to pay the full cost of your care, but you’ll pay a bigger share.
Dentures (Complete or Partial)
Prosthetic (artificial) teeth that replace missing teeth. Dentures are in the form of an arch and are supported by the surrounding soft and hard tissues of the mouth. They are removable and typically made of acrylic resin with some metal. When dentures are supported by crowns that are attached to an implant, they are called implant-supported dentures or appliances.
Department of Health and Human Services
The federal cabinet-level agency that administers federal health, welfare and human services programs and activities. HHS has lead agency responsibility for significant aspects of the Patient Protection and Affordable Care Act and is home to the Centers for Medicare & Medicaid Services and its Center for Medicare and Medicaid Innovation, the Health Resources and Services Administration, the Centers for Disease Control and Prevention, the Agency for Health Care Research and Quality, the National Institutes of Health, the HHS Inspector General, the HHS Office for Civil Rights, the HHS Office of Minority Health, the Substance Abuse and Mental Health Services Administration, the Indian Health Service and other federal agencies.
Depression
(major depressive disorder or clinical depression) -- A common and serious medical illness that negatively affects how you feel, the way you think and how you act. Depression is a mood disorder that causes feelings of sadness and/or a loss of interest in activities once enjoyed. It can lead to a variety of emotional and physical problems and can decrease a person’s ability to function at work and at home.
DEXA
A bone density test that uses an x-ray to evaluate bone strength.
Diabetes (diabetes mellitus)
A chronic disease that affects your body’s ability to produce or use insulin. Insulin is a hormone. When your body turns the food you eat into energy (also called sugar or glucose), insulin is released to help transport this energy to the cells. Insulin acts as a “key.” Its chemical message tells the cell to open and receive glucose. If you produce little or no insulin, or are insulin resistant, too much sugar remains in your blood. If you have diabetes, no matter what type, it means you have too much glucose in your blood, although the causes may differ. Too much glucose can lead to serious health problems.
Dilation and Curettage (D&C)
Surgical procedures typically performed at the same time to open and widen (dilate) the cervix, and to scrape to remove the uterus lining (curettage).
Discount Dental Plan
A discount dental plan is not insurance. Instead, your plan contracts with a network of providers who have agreed to provide you with care at discounted rates. Since these plans are not insurance and they generally provide discounts on all services, they also may give discounts on cosmetic services, or other services that may not be covered by dental insurance. In a discount dental plan, you cover the full cost for every service. The plan does not pay for any services you receive. You pay for all of your care, but you get the plan’s discounted rates.
E
EKG
An abbreviation for electrocardiogram. Sensors, or electrodes, are placed on the skin to measure the electrical activity of the heart. The electrical activity, shown as a graph, helps physicians assess the regularity of a patient’s heartbeat.
Electrical Stimulation
Electrical stimulators and supplies are used for managing pain and wound healing.
Emergency Care
Services provided to treat an unexpected serious illness or injury that needs immediate medical attention.
Emergency Medical Treatment and Active Labor Act (EMTALA)
A law that requires hospitals and ambulance services in the U.S. to provide care to anyone needing emergency healthcare treatment regardless of citizenship, legal status or ability to pay. The law does not provide for reimbursement, and hospitals and ambulances are free to charge patients for providing the emergency care. Patients who receive emergency treatment can be discharged only after they give informed consent, or if, based on their condition, it would be appropriate to transfer them to a hospital better equipped to administer the treatment.
Endodontics
A dental specialty that focuses on diseases of the tooth pulp (nerve tissue) and the tissues surrounding the root of a tooth.
Endoscopy
A visual exam using a flexible fiberoptic scope to examine a specific part of the body. In an upper gastrointestinal endoscopy or esophagogastroduodenoscopy (EGD), the physician examines the upper digestive tract including the esophagus (swallowing tube), stomach and the duodenum, the upper part of the small intestines.
Episode of Care
A certain group of services and procedures that healthcare providers usually perform for complicated sicknesses or conditions, like diabetes or heart disease. Episodes of Care run from the time your symptoms start until all of your treatments end. If you have a condition that doesn't really "end," like diabetes, your episode starts with your first diagnosis, and continues while your doctor monitors you over the course of a year.
Epidural Anesthesia
Anesthesia administered through an injection near the spine; the patient is awake but numb from the chest to the legs. Epidurals are often used during childbirth.
ERISA (Employee Retirement Income and Security Act)
A law that sets standards and protections for employee health insurance and pension plans.
Eruption Aids
Procedures which help teeth grow (erupt) into the mouth and usually involve the removal of both soft and hard tissue located just over the tooth crown that can block the emergence of the tooth into the mouth.
Exam (Dental Evaluation)
A procedure including a visual assessment and other diagnostic aids, such as X-rays, to assess the health and condition of the teeth and soft and hard tissues of the mouth so that the dentist can determine a treatment plan.
Exchanges
State health insurance “marketplaces” created by the Patient Protection and Affordable Care Act. Exchanges are places where individuals and small employer groups can purchase and enroll in insurance plans. They are intended to make the process of choosing and enrolling in a health plan easier and transparent. They also help individuals calculate and apply for premium subsidies to help pay for coverage. Exchanges are responsible for quality oversight, certification of qualified health plans that can be sold in the exchange and other matters.
Exclusive Provider Organization (EPO)
A managed care organization that exhibits characteristics of both health maintenance organizations (HMOs) and preferred provider organizations (PPOs). Like an HMO, an EPO plan requires that members visit in-network providers only; care from out-of-network providers is not covered except in some cases for an emergency. Like a PPO, an EPO plan does not require you to “sign up” with a specific dentist and often allows members to see specialists without first obtaining a referral. These specialist visits are covered as long as the providers are in-network.
Experimental Treatment
A treatment that is not recognized or accepted by the professional medical community as proven and effective, or is not approved by the FDA or other federal agencies. This type of treatment may need further clinical trials or study, or there may not be enough evidence that the treatment is safe and effective. Experimental treatments are typically not covered by plans.
Explanation of Benefits (EOB)
Your plan will provide you with an EOB after you or your provider submit a medical or dental claim. The EOB will include a detailed explanation of how your plan determined the amount of reimbursement it made to your provider or to you for each service listed on the claim. The EOB will also include information on how to appeal or challenge that reimbursement decision. You may not receive an EOB for care that you receive from a provider or facility in your plan’s network if no additional payment is required for those services.
Extraction
The removal of one or more teeth, or parts of teeth, from the jaw and soft tissue. Extractions are typically considered a surgical procedure.
F
Facility Charge
A separate price that hospitals and ambulatory surgery centers may charge for performing a procedure at their location. Facility charges don’t include the cost of the surgery or procedure, just the cost for using the space.
FAIR Health
FAIR Health - A national, independent, not-for-profit corporation whose mission is to bring transparency to healthcare costs and health insurance information.
Femoral Hernia
A hernia that forms between the abdomen and thigh.
Fibroid
A benign (non-cancerous) lump or tumor, located in the muscle of the uterus (a women’s womb).
Fillings
A dental restoration or dental filling is a process that repairs a portion of a tooth by removing diseased tooth structure (decay). After the diseased material is removed, it is replaced with a dental material which helps restore the function, integrity and morphology of the missing tooth structure. If the filling is done directly in the mouth the material is usually amalgam or a composite resin.
Fluoride Treatment
The delivery of fluoride (in the form of gel, varnish or mouth rinse) to the tooth surface to prevent tooth decay. Fluoride also may be present in the drinking water to help prevent cavities in your community.
G
Gallbladder Removal (Cholecystectomy)
Surgery to remove an inflamed or infected gallbladder. The gallbladder is an organ that stores bile, which is made in the liver. Bile aids in the digestion of fatty foods.
General Anesthesia
A medically induced state of unconsciousness, resulting from the administration of one or more anesthetic drugs. General anesthesia allows dentists to perform procedures that would otherwise be painful or take too long, or would compromise the health of the patient.
Geozip
A geozip is a geographic area usually defined by the first three digits of U.S. zip codes. Geozips may include areas defined by one three-digit zip code or a group of three-digit zip codes. Geozips generally do not include zip codes in different states. When you search for a cost estimate, the results will be based on billed charges for procedures performed in the geozip that includes the zip code you entered.
Glaucoma
A group of eye conditions that damage the optic nerve; the optic nerve is vital for good vision. It usually happens when fluid builds up in the front part of your eye. That extra fluid increases the pressure in your eye, damaging the optic nerve. If untreated, it may damage the optic nerve, causing vision loss or even blindness.
H
Hard Tissue (Bone) Excisions
Procedures that remove or reshape bone from the mouth, which are usually performed to remove diseased tissue, or for cosmetic reasons.
Health Insurance Policy
A contract between you and your insurer that provides that your insurer will be required to pay for specific medical services (these will be defined in the policy) as long as your premium is paid. Having a health insurance policy does not mean that your insurer will pay for every medical service that you receive. It is important for you to know the services that are included for coverage in your health insurance policy and any requirements that you need to meet in order to have the insurer pay for the services. You will be responsible for paying for any services that you receive that are not covered by your policy unless your insurer/administrator states that you are not responsible.
Health Insurance Portability and Accountability Act (HIPAA)
A federal law that protects the privacy of individuals’ health information and regulates health insurance portability and non-discrimination, among other things. The HIPAA provisions were broadly expanded by the Patient Protection and Affordable Care Act.
Health Maintenance Organization (HMO)
An HMO is a health plan that typically has a closed network of physicians and other healthcare providers, and hospitals. With a traditional HMO plan, a member receives services from the HMO's providers for a predetermined co-payment. A member pays only co-payments for services and need not file claim forms unless he or she receives medical services outside the network. Non-emergency services received outside the network without prior plan approval are not covered by the plan.
Health Savings Account
A tax-advantaged savings account that a member can open to pay for qualified medical and dental expenses. Contributions to an HSA can be made by both a member and his or her employer, but the money belongs to the member. The money invested in an HSA is tax-deductible, and any earnings are tax-deferred. The member can withdraw funds tax-free and without penalty from the account if the funds are used to pay for qualified medical expenses. The HSA is portable and goes with the member if the member changes jobs. Tax references are applicable per federal tax regulations. State tax regulations may vary. (See the page about HSAs at the U.S. Department of the Treasury website.) (See the Internal Revenue Service's list of qualified medical and dental expenses.)
Healthcare Common Procedure Coding System codes
There are two main types of HCPCS codes: Level I and Level II codes.
Level I HCPCS codes are 5-character Current Procedural Terminology (CPT) Codes that are developed and maintained by the American Medical Association. CPT codes refer to professional services such as reading an MRI, giving a shot, seeing a patient for an office visit or performing surgery. There are 3 categories of Level I codes. Category I codes have 5 digits. Category II codes are used for performance measurement and have 4 digits followed by the letter F. Category III codes are used for emerging technologies, and have 4 digits followed by the letter T.
Level II HCPCS codes include one letter followed by 4 digits (e.g., A9999). Most Level II codes refer to services or items such as durable medical equipment (e.g., wheelchairs, crutches), ambulance services, vision and hearing supplies, injectable and chemotherapy drugs and prosthetic devices. Level II HCPCS codes are maintained by the Centers for Medicare and Medicaid Services (CMS), a division of the US Department of Health and Human Services. You may see a HCPCS code on your Explanation of Benefits form (EOB). You can also ask your healthcareprovider for the relevant HCPCS code(s) for a procedure or service you will undergo, or have already received.
Healthcare Provider
A healthcare professional (doctor, nurse, anesthesiologist, psychologist, etc.) or facility (such as a hospital or ambulatory surgery center) that is licensed and certified to perform certain services in their specialty.
Healthcare.gov
A website maintained by the Office of Consumer Information and Insurance Oversight of the Department of Health & Human Services that provides information to consumers on available insurance options, data on care quality and resources for disease prevention.
Heart Attack (Myocardial Infarction)
Occurs when the flow of blood to the heart is blocked, most often by a build-up of fat, cholesterol and other substances, which form a plaque in the arteries that feed the heart (coronary arteries). The interrupted blood flow can damage or destroy part of the heart muscle.
Hemorrhoid Removal
Surgery to remove hemorrhoids, which are swollen veins in the anal area that can bleed or be painful
Hernia
A hole, tear or other weakening where part of an organ is displaced and protrudes through the wall of the cavity containing it. Hernias can occur in different areas of the body, including the groin (inguinal hernia), navel, the site of a surgical incision, the abdomen and between the abdomen and thigh (femoral hernia). An organ or tissue can get stuck in a hernia.
HHS
See Department of Health and Human Services.
High-deductible health plan
A plan with a higher deductible than a traditional insurance plan. The deductible is the amount you have to pay yourself before your plan starts paying for your care. Because you pay more up front, these plans usually have lower monthly premiums than traditional plans.
HIPAA
See Health Insurance Portability and Accountability Act.
Hip replacement
A procedure in which a surgeon removes the damaged sections of your hip joint and replaces them with parts usually constructed of metal and very hard plastic, called an artificial joint or prosthesis. If your hip has been damaged by arthritis, a fracture, or other conditions, common activities such as walking or getting in and out of a chair may be painful and difficult. Your hip may be stiff, and it may be hard to put on your shoes and socks. You may even feel uncomfortable while resting. If medications, changes in your everyday activities, and the use of walking supports do not adequately help your symptoms, you may consider hip replacement surgery. Hip replacement surgery is a safe and effective procedure that can relieve your pain, increase motion, and help you get back to enjoying normal, everyday activities.
Hip revision (revision total hip arthoplasty)
A procedure in which the surgeon removes a previously implanted artificial hip joint, or prosthesis, and replaces it with a new prosthesis.
Hysterectomy
Surgery to remove a woman's uterus.
I
Imaging Tests
Tests that enable the healthcare professional to view organs, tissue, bone and other parts of the body. X-Rays, CT (Cat) scans, MRIs, PET scans and ultrasound are types of imaging tests.
Impaction
Occurs when a tooth has not fully moved (erupted) into its expected position in the mouth (jaw). Impaction might occur for many reasons. For example, there may not be enough room in the jaw to accommodate the tooth, the tooth's growth path may be obstructed by other teeth or the angle of the impacted tooth may not be straight. The most common impacted teeth are third molars or wisdom teeth.
Implant (Abutment) Supported
When a crown or appliance is placed directly onto the implant.
Implant (Breast)
A soft silicone shell filled with either silicone gel or a saline (saltwater) solution that is fitted under the breast tissue or chest muscle beneath the breast. Implants are used in breast reconstruction or augmentation surgery.
Implant Supporting Structures
Devices that help stabilize implants, or help replace missing teeth within the same arch.
Implants (Endosteal Implants)
Titanium rods that are surgically placed within the bone of the upper or lower jaw. They appear similar to an actual tooth root and support crown(s) to replace missing teeth. When they are first placed into the jaw, the bone of the jaw accepts the implant and grows into the implant structure to give the implant stability.
Incisions
Procedures that involve cutting into tissue to correct a diseased or compromised area. For example, incisions are made to help drain abscessed areas that are infected and filled with fluid.
Incontinences/Ostomy Supplies
Incontinence and ostomy supplies are medical devices that are used for collecting urine and waste materials.
Inguinal Hernia
A hernia that forms in the groin area.
Injections
A process that releases a drug into a patient’s soft tissue or bloodstream, usually by a needle. In dentistry, the most common injections are local anesthetics (numbing agents), which allow the dentist to perform dental services on patients without the patient feeling pain. Antibiotics can also be delivered by injection.
Inlays
Cast (gold or ceramic) restorations that fit within the crown of the tooth and are used in place of amalgam or composite fillings to restore function to the tooth. They offer the same benefits as fillings, but they cost more and may not be covered by the plan. Inlays also can be used to help replace a missing tooth (prosthetic inlay).
In-Network
Pertains to a group of providers (a network) who have contracted with your plan. The term also may be used to describe treatment from these in-network doctors, clinics, health centers, dental practices and other providers who have a contract with your plan to provide care for its members. Usually, you will pay less out of your own pocket when you receive treatment from in-network providers.
In-Network Price (on this website)
The most that a health plan will pay a doctor who takes your plan. If you have not met your deductible, you may have to pay the full amount. If you have met your deductible, you may only have to pay a co-pay (a fixed payment when you get care) or co-insurance (a percentage of the in-network price, like 15%).
Institutional Review Board (IRB)
A group of people appointed by an institution (such as a hospital or university) to review and monitor research projects involving human subjects, with the purpose of protecting the rights and welfare of the people who are participating as subjects in the research. An IRB seeks to ensure that subjects are not placed at undue risk, and that they give uncoerced, informed consent to their participation. To this end, an IRB has the authority to approve, disapprove and require modifications to research projects involving human subjects. Once a project is approved, the IRB must monitor the progress of the ongoing research, prospectively approve modifications and suspend the project if necessary to protect subjects.
Intravenous Infusion (also known as IV)
Intravenous (“within a vein”) infusions are fluids and drugs administered through a needle or tube that is inserted directly into a vein. General anesthesia is often administered through intravenous infusion. See General Anesthesia.
J
K
L
Laughing Gas/Nitrous Oxide
A gas (N2O) that a patient inhales, which helps reduce anxiety when the patient is getting dental treatment. It may not be covered by your plan, so you should consult with your plan to find out.
Lifetime Maximum Benefit
The total amount of money that a plan will pay for a member’s care during his or her lifetime. In dental plans, an orthodontic benefit usually has a lifetime benefit maximum.
Low back pain
A common disorder involving the muscles, nerves, and bones of the back. Pain can vary from a dull constant ache to a sudden sharp feeling. LBP may be classified by duration as acute (pain lasting less than 6 weeks), sub-chronic (6 to 12 weeks), or chronic (more than 12 weeks). The condition may be further classified by the underlying cause as either mechanical, non-mechanical, or referred pain. The symptoms of LBP usually improve within a few weeks from the time they start, with 40-90% of people completely better by six weeks. In the common presentation of acute LBP, pain develops after movements that involve lifting, twisting, or forward-bending. The symptoms may start soon after the movements or upon waking up the following morning. The description of the symptoms may range from tenderness at a particular point to diffuse pain. It may or may not worsen with certain movements, such as raising a leg, or positions, such as sitting or standing. Pain radiating down the legs (known as sciatica) may be present.
Lumpectomy (also known as breast-conserving surgery)
This procedure removes tumors and small portions of the surrounding healthy tissue while conserving the breast. Implants are used in breast reconstruction or augmentation surgery.
M
Mammogram
A low-dose x-ray of breast tissue that is often used to screen and diagnose abnormal growths in the breast.
Mastectomy
Surgery to remove a breast. Mastectomy can be performed for cases of breast cancer or as a prophylactic surgery when the patient is at an increased risk of developing tumors in the breast.
Maximum Allowable Amount
The maximum dollar amount that an insurer will consider reimbursing for a covered service or procedure. This dollar amount may not be the amount ultimately paid to the member or dental provider as it may be reduced by any co-insurance, deductible or amount beyond the annual maximum. Some plans may refer to the "allowable amount" as the "maximum allowable amount;" these terms have a similar meaning.
Medicaid
A government health plan that covers low-income families. Medicaid (along with Medicare) also pays for most of the country’s nursing home and home care costs. Medicaid is jointly funded by states and the federal government. Each state has its own Medicaid program, so coverage and benefits are different from state to state.
Medicare
The federal health insurance program for individuals ages 65 and older, as well as persons with end-stage renal disease and certain persons with disabilities. Medicare covers beneficiaries for hospital, post-hospital extended care, and home healthcare, as well as a range of medical care services and benefits. Medicare enrollment is compulsory for all individuals covered by the Social Security Act. At their option, Medicare beneficiaries can buy “Part D” outpatient prescription drug coverage. Beneficiaries can elect to enroll either in “traditional” Medicare (which allows patients to receive care from any participating physician, hospital or healthcare supplier) or through Medicare Advantage Plans, most of which restrict patients to specific network providers while typically offering additional benefits and coverage. The Patient Protection and Affordable Care Act expands Medicare coverage for preventative services and additional levels of prescription drug coverage while also introducing reforms to improve healthcare quality and efficiency.
Member
An eligible employee or an eligible dependent of an employee who has enrolled in the plan. Also called enrollee or participant.
Mini Implant
A small implant placed into the bone to help replace missing teeth in a dental arch. Mini implants can fit into tight places, cost less than standard implants and require less bone support. A mini implant can be placed in one visit, whereas the standard implant requires two visits.
Miscellaneous Services
Services that do not fall into any single category of dental care but that can be performed across many categories of care. For example, general anesthesia can be used when a patient is undergoing oral surgery or endodontic treatment.
Mouth guards
There are two primary types of mouth guards. One is an athletic mouth guard, which is used to protect teeth when playing sports. The other is an occlusal (night) guard, which helps protect the teeth from the effects of bruxing (grinding).
MRI Scan
Abbreviation for Magnetic Resonance Imaging; an imaging test that uses magnetic fields and radio waves to take detailed pictures of the inside of the body.
Myomectomy
Surgery to remove uterine fibroids, which leaves the uterus in place.
Myringotomy
In this surgery, a small hole is made in the ear drum and, in many cases, a small tube is inserted into the hole, to drain fluid that becomes trapped in the middle ear.
N
Narrow network
A type of healthcare plan that only allows members to use a limited number of doctors. As a trade-off, monthly premiums are usually lower.
Nerve Block
An injection that can help to relieve pain by interrupting signals sent by an affected nerve to the brain.
Non-covered Services
Medical or dental services that are not included in your plan, or that the plan may not pay for because you have exceeded either the annual maximum or the frequency or age limits for the service. If you receive non-covered services, your plan will not reimburse for those services, and your provider will bill you. You will be responsible for the full cost of the services you receive. You will need to consult with your insurer to determine what services are covered and when.
O
Obamacare
See Affordable Care Act (ACA).
Occlusal (Night) Guard
A mouth guard that is placed inside the mouth on the teeth to help protect teeth from the effects of bruxing (grinding).
Office Visits/Patient Visits
Dental visits that do not involve performing a specific dental procedure. The time the dentist or other provider spends with you in the office is billed as an office visit. In contrast, when a specific procedure is performed, a specific dental procedure code for that procedure, known as a CDT code, is billed instead. The cost of the office visit is included as part of the procedure. See CDT® or Current Dental Terminology.
Onlays
Cast (gold or ceramic) restorations that extend onto the crown of the tooth to help support areas of the tooth that have extensive decay or fracture. Compared to crowns, onlays may be a bit more conservative than full crown coverage. When an onlay is used to help replace a missing tooth, it is called a prosthetic onlay; if it is used to restore a tooth to function, it is a restorative onlay.
Open enrollment period
The time of year when people can join a private health or dental plan. This period usually happens a few weeks before the new coverage year begins. For example, if your dental plan coverage runs from January 1 through December 31, open enrollment might be in November. The open enrollment period to sign up for the ACA’s state Marketplaces can be found at www.healthcare.gov.
Orthotic Devices
Orthotics are medical devices that are used for treatment of the neuromuscular and skeletal system.
Orthopedics
The medical specialty that deals with the treatment of the musculoskeletal system, including bones, joints, muscles, ligaments and tendons.
Osteoarthritis
A type of joint disease that results from breakdown of joint cartilage and underlying bone. The most common symptoms are joint pain and stiffness. Initially, symptoms may occur only following exercise, but over time may become constant. Other symptoms may include joint swelling, decreased range of motion, and when the back is affected weakness or numbness of the arms and legs. The most commonly involved joints are those near the ends of the fingers, at the base of the thumb, neck, lower back, knee, and hips. Joints on one side of the body are often more affected than those on the other. Usually the symptoms come on over years. It can affect work and normal daily activities. Unlike other types of arthritis, only the joints are typically affected.
Out-of-Network
Pertains to treatment from providers (doctors, dentists, etc.) who do not have an agreement with your insurer to provide care to its members. You typically will pay more out of your own pocket when you receive treatment from out-of-network providers.
Out-of-Network Benefits
Benefit plan coverage for services provided by healthcare professionals who are not under a contract with your health or dental plan. You may have to pay more for these benefits than you would for in-network benefits. You should consult your plan to find out how they are covered.
Out-of-Pocket Cost
Portion of the cost of medical or dental services that the plan member must pay. This cost may represent the difference between the amount charged by an out-of-network provider and what a plan is willing to reimburse for out-of-network services. If you receive services within the network, your out-of-pocket costs could be the amount of your copays or co-insurance and any deductible you have to pay first.
Out-of-Pocket Maximum
The limit on the total amount a health insurance company requires a member to pay in deductibles, copays and co-insurance for in-network care in a year. After reaching an out-of-pocket maximum, a member no longer pays because the plan will begin to pay 100 percent of expenses. This only applies to covered services. Members are still responsible for services that are not covered by the plan, even if they have reached the out-of-pocket maximum for covered expenses. Members also continue to pay their monthly premiums to maintain their insurance policies.
P
Palliative Care
care provided to an individual to help relieve discomfort or pain. A temporary solution to manage pain, palliative care is not a final treatment. In most cases another appointment is required to complete treatment.
Pathology Services
services performed by a laboratory to gather information from samples taken from the tissues or fluids from the mouth or other parts of the body.
Pap Smear
Also called a pap test; a test which involves taking a sample of cells from the cervix (the opening to the uterus) to screen for cervical cancer in women.
Participating Provider
A physician, dentist or other healthcare professional, hospital or healthcare facility that contracts with your health insurer to provide services to its members at a specific fee amount.
Participating Provider (dental)
A dentist or other healthcare professional, hospital or healthcare facility that contracts with your dental or health insurer to provide services to its members at a specific fee amount.
Pathology
The study of the nature and course of a disease; pathology reports describe the diagnosis and process of a disease after examination of tissue and other samples.
Pathology Services
services performed by a laboratory to gather information from samples taken from the tissues or fluids from the mouth or other parts of the body.
Patient Protection and Affordable Care Act
The formal name of the health reform law enacted in 2010.
Percentile
A statistical measure used to describe how a particular quantity (such as the cost of a specific healthcare procedure) varies across a range of sources (such as all the doctors in your area.) For example, 50% of all fees billed by providers are at or below the level indicated by the 50th percentile; 80% of all fees billed by providers are at or below the level indicated by the 80th percentile. Percentiles are important because they are used by many insurers in determining the highest level of a billed charge that they will consider for reimbursement.
Periodontal (Gum) Services
These are the services that treat diseases of the supporting structures of the tooth, both the bone and soft tissue. These services run a wide range of treatment, from non-surgical procedures, such as scaling and root planning, to surgical procedures such as bone grafts and soft tissue grafts.
Periodontal Hard (Bone) Surgeries
Dental surgeries performed on the supporting tissues of the teeth to remove, reshape or add (graft) bone to help restore function and cosmetics to the area. These surgeries help correct defects in the bone, which are often caused by periodontal disease.
Periodontal Maintenance
The period following periodontal therapy (active treatment such as scaling and root planing) when the dentist observers and tracks the results of the periodontal therapy and identifies areas that may need additional treatment. Maintenance may consist of the removal of plaque and calculus (where bacteria live), local scaling and root planing, x-rays when appropriate and other procedures, based on the patient’s response to the initial therapy.
Periodontal Services
Care to treat diseases of the supporting structures of the tooth (both the bone and soft tissue). These services include non-surgical procedures, such as scaling and root planing, as well as surgical procedures, such as bone and soft-tissue grafts.
Periodontal Soft Tissue Surgeries
Dental surgical services that involve only the soft tissue that surrounds the teeth. These surgeries help correct defects, many of which were caused by periodontal disease. These surgeries can include removing diseased tissue, reshaping tissue or adding (grafting) tissue into an area to help improve function and appearance.
Periodontal Splinting
A procedure that attaches weak, loose teeth together with stronger, non- diseased teeth, turning them into a single unit that is stronger than the individual teeth. The reason for the teeth being loose is usually due to periodontal disease, which often causes a loss of bone support. The procedure can be performed in a number of ways, the most common of which is to use a composite (white) material to join the teeth together. Many dental plans do not cover splinting.
Physician
An individual who has received a “Doctor of Medicine” (MD) or Doctor of Osteopathic Medicine (DO) degree and is licensed to practice medicine in their state.
Pin Retention
When a tooth is badly broken down, options for restoration can be a crown or a direct amalgam (silver) or composite (white) filling. If a direct filling is chosen, metal pins may be used to help hold the filling in place.
Pneumonia
A bacterial, viral, or fungal infection of one or both sides of the lungs that causes the air sacs, or alveoli, of the lungs to fill up with fluid or pus. Symptoms can be mild or severe and may include a cough with phlegm (a slimy substance), fever, chills, and trouble breathing. Many factors affect how serious pneumonia is, such as the type of germ causing the lung infection, your age, and your overall health. Pneumonia tends to be more serious for children under the age of five, adults over the age of 65, people with certain conditions such as heart failure, diabetes, or COPD (chronic obstructive pulmonary disease), or people who have weak immune systems due to HIV/AIDS, chemotherapy (a treatment for cancer), or organ or blood and marrow stem cell transplant procedures.
Point of Service (POS) Plan
A health plan that allows you to choose at the time medical services are to be received whether you will go to a provider within your plan’s network or seek care outside the network.
Pontics
False teeth that are used to replace missing natural teeth. They can be made from gold, porcelain or other materials. They are typically used as part of a bridge. See Bridge.
Post & Cores
These restorations follow root canal treatment and are placed inside the tooth, within the tooth center and root. A post & core will be used when the remaining tooth structure will not support or retain a crown, as a result of decay, fracture or other cause.
Preauthorization
A process that your health or dental plan goes through to make a decision that a particular service, treatment plan, prescription drug or other service prescribed by your provider is covered and necessary. Your plan may require preauthorization for certain services before you can receive them. Preauthorization requirements are generally waived if you need emergency care.
Pre-existing condition
A health condition that exists for a set time prior to enrollment into a health plan, regardless of whether the condition has been formally diagnosed. The Patient Protection and Affordable Care Act prohibits insurers and employer-sponsored health plans from denying or limiting coverage to individuals with pre-existing health conditions.
Preferred Provider Organization (PPO)
A health plan that is designed to encourage you to receive your healthcare through a network of selected healthcare providers (such as hospitals and physicians). If your plan is a PPO, your medical expenses will be lower if you use a provider or facility that is part of your plan’s network. You are entitled to receive reimbursement for care from providers and facilities that are outside the network, but you may pay a larger portion of the charges for such "out-of-network" care.
Premium
The amount a consumer (or employer) pays to a health or dental insurance company for coverage. The insurance company generally recalculates the premium each policy year. This amount is usually paid in monthly installments. When a consumer receives insurance through an employer, the employer generally pays a portion of the cost of the premium and the consumer pays the rest, often through regular payroll deductions.
Preventive Care
Care designed to keep people healthy, and stop them from getting sick or hurt. It often includes vaccines and screening tests. A key part of preventive medicine is making sure patients know how to get healthier by changing their lifestyles.
Primary Care Physician (PCP)
A family doctor, internist or pediatrician who coordinates your care or your family’s care. Some types of plans, like a POS or HMO, require that you visit your PCP first for any care that you need. But even if you’re not required to use a PCP, it’s a good idea to develop a relationship with a primary care doctor who knows your medical history and can make sure you’re getting the care you need.
Prostate
Part of the male reproductive system; a gland that produces and stores seminal fluid, the milky liquid that forms part of semen. An enlarged prostate usually causes difficulty in urination, because the urethra (the tube that carries urine out of the body) runs through the prostate gland.
Prostate Cancer
A cancer that occurs in a man's prostate — a small walnut-shaped gland that produces the seminal fluid that nourishes and transports sperm. Prostate cancer begins when cells in the prostate gland start to grow uncontrollably. Some prostate cancers can grow and spread quickly, but most grow slowly.
Prosthesis (Prosthetic Appliance)
A fixed or removable dental appliance used to replace one or more lost or missing natural teeth in an arch.
Prosthetic Adjustments
Common dental procedures that selectively grind on the teeth to adjust the bite, or grind on the base material of the denture to relieve an area of discomfort. This common procedure for all prosthetics is performed after the appliance is placed in the mouth and used by the patient while talking and eating for several days to identify areas that should be adjusted.
Provider
A doctor or other healthcare professional, hospital or healthcare facility that is accredited, licensed or certified to practice in their state, and is providing services within the scope of that accreditation, license or certification.
Provider (dental)
A dentist or other healthcare professional, hospital or healthcare facility that is accredited, licensed or certified to practice in the state, and is providing services within the scope of that accreditation, license or certification.
Provider network
Doctors and other healthcare professionals who agree to provide medical care to members of a health plan, under the terms of a contract.
Provider network (dental)
Dentists and other healthcare professionals who agree to provide care to members of a dental or health plan, under the terms of a contract.
Prudent Layperson Standard
Under PPACA, a condition with acute symptoms of sufficient severity (including severe pain) that a person who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in—(i) placing the health of the individual (or an unborn child) in serious jeopardy, (ii) serious impairment of bodily functions, or (iii) serious dysfunction of any bodily organ or part.
PSA Test
A blood test that measures levels of prostate-specific antigen (PSA). High levels of PSA may be a sign of prostate cancer.
Pulp (Pulp Tissue)
Nerves and blood vessels that are located in the middle of the tooth, in what is called the pulp chamber, and conduct sensations such as pain and hot/cold temperature.
Pulp Caps
A procedure to place a medicated dressing over a small area of pulp (nerve and blood vessel tissue). Pulp caps can be direct or indirect. For a direct pulp cap, a medicated dressing or cement is placed over a small area of exposed pulp (nerve) during a cavity preparation to stimulate reparative dentin to avoid inflammation or infection of the pulp tissue. For an indirect pulp cap, the medicated dressing or cement is placed over a small area above the pulp, but the pulp is not exposed. This will promote healing of the tissue so the tooth can be restored.
Pulp Test
A procedure performed to help determine the health of the tooth. Depending on how the tooth responds to the pulp test, the tooth may require dental work. The pulp test is typically combined with other diagnostic procedures before a final treatment decision is made.
Pulp Therapy
Treatments that are applied to pulp tissue, usually involving endodontic treatment, such as root canals.
Proxy
A person who is legally allowed to make healthcare decisions for another person—also known as a “healthcare proxy.” When you pick someone to be your healthcare proxy, that person can make decisions about your medications and other treatments when you can’t make those decisions yourself. This could be toward the end of your life or during a temporary illness or injury. The term healthcare proxy can also refer to the legal document that names the person you’ve picked to make healthcare decisions for you.
Q
Qualified Medical Expenses
Qualified Medical Expenses - Qualified medical expenses (which also apply to qualified dental expenses) are defined under Section 213 of the Internal Revenue Code. (See The Internal Revenue Service's Publication 502 about medical and dental expenses.) Qualified dental, medical and other expenses permitted to be reimbursed from health savings accounts (HSAs) include, but are not limited to, the following:
• Dental care;
• Doctors' visits;
• Ambulance and hospital services;
• Prescription drugs and certain over-the-counter prescription medications;
• Durable medical equipment (DME);
• Acupuncture;
• Chiropractic services;
• COBRA healthcare continuation coverage;
• Qualified long-term care services and limited long-term care premiums;
• Vision care;
• Health insurance premiums for individuals receiving unemployment compensation; and
• At age 65 and over, Medicare Part A and B, Medicare HMO, and a member's share of employer-sponsored health insurance premiums (but not Medicare Supplement premiums).
A medical or dental expense is not a qualified expense if a member receives reimbursement for it under insurance coverage. If the member's expense is paid for or reimbursed by an HSA account, that expense cannot be included for purposes of determining itemized tax deductions.
R
Radiation Therapy
A type of therapy used to destroy cancer cells and other diseases with high-energy particles.
Rebase
A process that involves refitting either a complete or partial denture in the mouth by replacing the denture base material (acrylic). This process does not typically replace the teeth.
Reimbursement
The amount that your health plan pays for a specific service. For instance, your insurer’s reimbursement rate (allowed amount) for a treatment may be up to $80. If your doctor charges $100, and is out of network, then you would be responsible for the remaining $20. If your doctor is in network, then $80 is the negotiated fee and you won’t have to pay the remaining $20.
Reline
Replacement of the inner surface of a complete or partial denture that is in contact with the soft tissues of the mouth to make it fit more securely. See Tissue Conditioning.
Respirator and Oxygen Equipment
Respirator and oxygen equipment are used by people who have difficulty breathing.
Root Canal
Provided within the tooth, root canal treatment involves removing the nerve and blood supply from the tooth, cleaning and widening the canal spaces and placing a filling material.
Root Planing
A process that removes or eliminates dental plaque and calculus (where bacteria live) on the root surface of the tooth.
S
Soft Tissue Excision
A procedure that removes soft tissue that is diseased or impedes the normal function of the mouth.
Space Maintainers
Metal or plastic appliances that help save space for permanent teeth when baby teeth (usually back teeth) are lost prematurely.
Stainless Steel Crowns
Pre-fabricated metal crowns used by dental professionals to repair a badly decayed baby or permanent tooth to protect it from further damage. Stainless steel crowns, often used with young patients, are very durable and can be expected to function well for many years, but are not considered permanent restorations.
Steroids
Medicine that is used to help relieve pain and inflammation in specific parts of the body. Steroids are available in pill, inhaled and enema forms or may be injected into specific body parts to relieve joint pain. Cortisone shots are a form of steroids used to relieve pain in the ankle, elbow, hip, knee, shoulder, spine and wrist.
Stress Test
Often performed to assess the health of the heart, this test measures how the body functions under stress. The patient’s change in blood pressure, pulse and heart activity is measured during a gradual increase in physical activity.
Stroke
Occurs when the blood supply to part of your brain is interrupted or severely reduced, depriving brain tissue of oxygen and nutrients. Within minutes, brain cells begin to die. There are two main types of stroke: ischemic, due to lack of blood flow, and hemorrhagic, due to bleeding. They result in part of the brain not functioning properly. Signs and symptoms of a stroke may include inability to move or feel on one side of the body, problems understanding or speaking, feeling like the world is spinning, or loss of vision to one side. Signs and symptoms often appear soon after the stroke has occurred. If symptoms last less than one or two hours it is known as a transient ischemic attack (TIA) or mini-stroke. The main risk factor for stroke is high blood pressure. Other risk factors include tobacco smoking, obesity, high blood cholesterol, diabetes mellitus, previous TIA, and atrial fibrillation.
Surgery - Extractions and Impactions, Biopsy
The term extraction describes the removal of one or more teeth or parts of teeth from the supportive bone and tissue. Extractions are typically considered to be a surgical procedure.
An impacted tooth refers to a tooth that has failed to emerge fully into its expected position in the jaw. This might occur for several reasons, such as not enough room in the jaw to accommodate the tooth, the tooth's eruption path is obstructed by other teeth or because the angle of the impacted tooth is not proper. The most common impacted teeth are 3rd molars or wisdom teeth.
Biopsy is a surgical procedure to remove an abnormal area of tissue. If all this abnormal area is to be removed, it is an excisional biopsy. If only a part of the abnormal area is to be removed, it is called an incisional biopsy. This tissue is removed so that it can be evaluated microscopically to determine if it is dangerous.
An impacted tooth refers to a tooth that has failed to emerge fully into its expected position in the jaw. This might occur for several reasons, such as not enough room in the jaw to accommodate the tooth, the tooth's eruption path is obstructed by other teeth or because the angle of the impacted tooth is not proper. The most common impacted teeth are 3rd molars or wisdom teeth.
Biopsy is a surgical procedure to remove an abnormal area of tissue. If all this abnormal area is to be removed, it is an excisional biopsy. If only a part of the abnormal area is to be removed, it is called an incisional biopsy. This tissue is removed so that it can be evaluated microscopically to determine if it is dangerous.
Surgical Extraction
The removal of one or more teeth or parts of teeth from the supportive bone and tissue, usually by elevating a flap of soft tissue and removing some of the supporting bone. Extractions are typically considered to be a surgical procedure.
Surgical Repairs
Procedures which help correct a diseased or defected area.
Synvisc
An elastic and viscous artificial fluid made from hyaluronan, a substance found in actual joint fluid. Synvisc may be injected to lubricate and cushion the joint to relieve pain associated with advanced cases of osteoarthritis.
Scaling
The removal or elimination of dental plaque and calculus (where bacteria live) on the tooth, usually on the crown of the tooth.
Sealants
Thin plastic coatings, typically used for children, that are applied to the grooves on the chewing surfaces of the back teeth to protect them from tooth decay. The grooves of children’s back teeth are the areas most prone to tooth decay and are most at risk when the tooth first erupts into the mouth.
Sedation
The use of drugs to calm and relax a patient prior to and during a medical or dental procedure. The drugs usually belong to a class called sedatives, which act by depressing the central nervous system, specifically those areas that control conscious awareness.
Sedative Filling
A temporary restoration placed on a tooth to insulate the nerve and reduce pain from an irritated or inflamed pulp (nerve). The filling should reduce the chance that saliva or bacteria will leak into the tooth and should be replaced with a permanent restoration once the tooth is calm.
Self-Insured
If you work for a large employer or group of employers, your plan may be self-insured. Self- insured means that your employer pays medical claims from their bank account and establishes the plan design. The benefits may be administered from a third-party administrator (“TPA”) or a Health Plan. Self- insured plans are not under the control of the Department of Insurance and the employer bears the cost for all utilization.
Sleep Apnea Devices
Sleep apnea devices are used to increase airflow to the lungs.
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Telehealth
The use of various forms of electronic information and communication technologies to support the delivery of non-clinical health care services. These services can include provider training, administrative meetings, discussions regarding the assessment, diagnosis, and management of the patient, as well as consultation, treatment, education, care management and/or self-management of a patient at a distance. Modes of delivery include but are not limited to, phone conversations, remote training, real-time video conferencing, electronic consultations and remote patient monitoring. The use of technology eliminates geographic barriers in the delivery of healthcare services. The definition of Telehealth services varies by payer and accordingly, coverage and reimbursement is at the discretion of the individual payer.
Telehealth (dental)
The use of various forms of electronic information and communication technologies to support the delivery of non-clinical health care services. These services can include provider training, administrative meetings, discussions regarding the assessment, diagnosis, and management of the patient, as well as consultation, treatment, education, care management and/or self-management of a patient at a distance. Modes of delivery include but are not limited to, phone conversations, remote training, real-time video conferencing, electronic consultations and remote patient monitoring. The use of technology eliminates geographic barriers in the delivery of healthcare services. The definition of Telehealth services varies by payer and accordingly, coverage and reimbursement is at the discretion of the individual payer.
Telemedicine
The use of various forms of telecommunication and electronic information technologies to provide clinical health care services at a distance. Telemedicine can improve access to medical services that may not be available for many reasons, including geographic or emergency care situations, care provided after regular office hours, and facilitates the transmission of medical, imaging and health informatics data from one site or individual to another. Telemedicine seeks to improve a patient’s health by permitting two-way, real time interactive communication between patients and medical staff with both convenience and privacy, and is viewed as a cost-effective alternative to the more traditional face-to-face way of providing medical care. The definition of Telemedicine services varies by payer and accordingly, coverage and reimbursement is at the discretion of the individual payer.
Telemedicine (dental)
The use of various forms of telecommunication and electronic information technologies to provide clinical health care services at a distance. Telemedicine can improve access to medical services that may not be available for many reasons, including geographic or emergency care situations, care provided after regular office hours, and facilitates the transmission of medical, imaging and health informatics data from one site or individual to another. Telemedicine seeks to improve a patient’s health by permitting two-way, real time interactive communication between patients and medical staff with both convenience and privacy, and is viewed as a cost-effective alternative to the more traditional face-to-face way of providing medical care. The definition of Telemedicine services varies by payer and accordingly, coverage and reimbursement is at the discretion of the individual payer.
Tissue Conditioning
A dental process whereby a conditioning material (gel) is placed inside a prosthetic appliance to help re-establish tone and health to the irritated soft tissue under the appliance.
Tonsillectomy
Surgery to remove the tonsils, which are glands located at the back of the throat.
Transurethral Resection of the Prostate (TURP)
Surgery to remove the part of the prostate gland that is blocking the flow of urine.
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Ultrasound
Also referred to as a sonogram, this test uses sound waves to create images of the inside of the body.
Upper GI Endoscopy [esophagogastroduodenoscopy (EGD), also known as an upper endoscopy or upper gastrointestinal endoscopy]
A procedure that lets your doctor look at the inside lining of the esophagus, stomach, and the first part of the small intestine (duodenum). In an EGD, the doctor uses an endoscope, a flexible, tube-like, telescopic instrument with a tiny camera mounted at its tip, to examine images of the upper digestive tract displayed on a monitor in the examination room. Small instruments may also be passed through the tube to treat certain disorders or to perform biopsies (remove small samples of tissue).
Upper Respiratory Infection (URI)
A nonspecific term used to describe acute, short-term infections involving the nose, paranasal sinuses, pharynx (the cavity behind the nose and mouth), larynx (voice box), trachea, and bronchi. Acute URIs include rhinitis, pharyngitis/tonsillitis and laryngitis often referred to as a common cold, and their complications: sinusitis, ear infection and sometimes bronchitis. Symptoms of URIs commonly include cough, sore throat, runny nose, nasal congestion, headache, low grade fever, facial pressure and sneezing. Most infections are viral in nature and in other instances the cause is bacterial. In uncomplicated colds, cough and nasal discharge may persist for 14 days or more even after other symptoms have resolved.
Upstate Health Research Network (UHRN)
The Upstate Health Research Network is a team of researchers comprised of health policy experts, statisticians, economists, and healthcare professionals from New York State and across the country which was tasked with assisting FAIR Health enhance and refine the methodologies and processes underlying its comprehensive database of healthcare claims. The UHRN is led by Syracuse University and includes researchers from Cornell University, University of Rochester, University at Albany (SUNY), University at Buffalo (SUNY), and SUNY Upstate. The University of Illinois, Indiana University, University of Colorado Denver and Arizona State University joined the UHRN as adjunct research institutions.
Urinary Tract Infection (UTI)
An infection in any part of your urinary system: your kidneys, ureters (the duct connecting the kidneys and bladder), bladder, or urethra. Most infections involve the lower urinary tract — the bladder and the urethra. Women are at greater risk of developing a UTI than men are. Infection limited to your bladder can be painful and annoying. Serious consequences can occur if a UTI spreads to your kidneys.
Usual and Customary Rate (UCR)
A term often used to describe a level of reimbursement that insurers use to calculate reimbursements for out-of-network care. If your plan covers some out-of-network care, your insurer may base the payment on a price that it determines to be “usual, customary and reasonable” in your area. It’s a good idea to find out this rate and then ask your provider how much he or she will charge for the service you need. To understand your plan’s UCR, contact your insurer. That way, you can make an informed decision and you won’t be surprised by a large out-of-pocket expense.
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Vaginal Delivery
A birth in which the child is pushed out of the mother's uterus via the vagina, as opposed to being delivered surgically (e.g., C-section).
Veneers
Thin layers of restorative material placed over a tooth surface, to improve the appearance of the tooth, or to protect a damaged tooth surface. Veneers can be made from composite or porcelain. A composite veneer may be created directly in the mouth, or produced by a technician in a dental laboratory. In contrast, a porcelain veneer may only be produced in a lab and then bonded to the tooth.
Once created, all veneers are bonded to the tooth, typically using a resin cement.
Vestibuloplasty
The surgical preparation of the alveolar ridge to restore the height of the bone (jaw bone where the teeth are located) in preparation for dentures or oral implants. The extent of the surgery varies, depending on the amount of bone loss incurred and the size of the surface area requiring reconstruction.
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Wisdom Teeth
The third and last molars on each side of the upper and lower jaws. They are the final teeth to grow into the mouth; this usually occurs in a person’s late teens or early twenties. Since wisdom teeth come in later in life, they may not fit into the mouth. This can lead to wisdom teeth that are impacted (growing below the gum line, and not fully erupted into the mouth).
Wound Care Supplies
Wound care supplies are used for improving the healing of a wound.
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X-rays (dental)
Two dimensional pictures of the teeth, bone and surrounding soft tissue that are used to help determine the health or disease of the teeth, soft tissue or bone. If the X-ray is taken with the film inside the mouth, it is an intraoral X-ray. If the film is placed outside the mouth, the X-ray is an extraoral X-ray.
X-ray (medical)
Uses small electromagnetic radiation to take pictures of the body.
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