Insurance Basics: New York State GlossaryThe health reform law enacted in 2010. (The formal name is the Patient Protection and Affordable Care Act - PPACA.)
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 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.
The maximum amount that an insurer will consider to pay for a service, including any amount that the patient will be responsible for paying. For in-network providers, the allowed charge is based on the contracts with the providers. For out-of-network providers, the allowed charges may be:
The most that a plan will pay in a plan year (this may be different from a calendar year). As part of the Affordable Care Act (ACA), most health plans cannot impose an annual maximum for “essential health benefits” like maternity care, hospital stays or prescription drugs. Dental plans are allowed to impose annual maximums.
A number issued by your insurer authorizing the health insurance company to pay for your care. You may need to obtain an approval number from your insurer before you see a particular doctor or receive a particular medical service in order for your health insurance company to pay for that visit and/or service. Your doctor’s office staff might be able to help you obtain the approval number from your insurer.
A swelling or bump, built up in the tissue of the body, filled with pus that is usually caused by an infection and can be identified by pain swelling or redness. An abscess might need to be drained or treated with antibiotics.
a crown or other appliance which is placed on a support (abutment) directly over an implant.
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.
A drug a provider gives a patient to numb part of the body for a short time and to help prevent pain during medical or dental procedures.
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.
refers to the techniques that are used to help close the root apex (tip) of a permanent tooth, when the pulp tissue has experienced decay or trauma and the root has not completely formed.
the surgical removal of the very tip of the root of a tooth that has had a root canal. During this procedure, the tip of the root is removed, and any areas of infection around the root tip are cleaned.
a device placed in the mouth to serve a number of functions, such a replacing and stabilizing teeth.
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.
Surgery to remove the adenoids, which are glands located in the back of the nose near the throat.
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).
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.
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.
A chronic, ongoing disease in which the airways in the lungs become constricted, swollen and inflamed, making it difficult to breathe.
Balance billing is 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. This means that if the defined out-of-pocket for the member was 20% of the provider’s charge and the member pays more than 20% - not due to a deductible application – this is a balance bill. This situation happens when a provider does not participate in a member's provider network.
The amount billed by your physician or other healthcare 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 its 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.
a process that uses techniques to gain the cooperation and trust of fearful patients, usually children, during dental visits.
a surgical procedure to remove an area of abnormal tissue so that it can be studied microscopically. There are different types of biopsies. In an excisional biopsy, all of the abnormal tissue is removed. In an incisional biopsy, only a part of the abnormal tissue is removed.
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.
The process of attaching a tooth-colored material (plastic) to a tooth by a dentist to fix a decayed, chipped, broken, or discolored tooth. It may also be used on a healthy tooth to change the appearance as a cosmetic procedure. It is an alternative to metal fillings. Bonding can typically be done in one dentist visit.
connect 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 (false tooth). (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.
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
An imaging test that uses a radioactive “tracer” to detect changes in the bone, which may indicate bone injury or disease.
Cancer that forms in tissues of the breast.
Surgery to reduce the size and reshape the breast, also known as reduction mammoplasty.
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 American Dental Association (“ADA”).
A detailed bill that your health care provider (such as your doctor, clinic, or hospital) sends to your health plan. This bill shows exactly what services you received.
A federal law that lets some people who lose their group health coverage stay on their plan for a limited time, and pay for it themselves. 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.
Co-insurance is a cost sharing feature of many plans. It requires a member to pay out-of-pocket a prescribed portion of the cost of covered healthcare expenses. The defined co-insurance that a member must pay out-of-pocket is based upon his or her health plan design. Co-insurance is established as a predetermined percentage of the allowed amount for covered services and usually applies after a deductible is met in a deductible plan, such as deductible HMO, preferred provider organization (PPO), point-of-service (POS), and indemnity plans.
A form of medical cost sharing in a health insurance plan that requires the member to pay a fixed dollar amount for each visit to a doctor or for a specific service. This fee is pre-set; it will be specified in your health insurance policy and also may be listed on your insurance card.
Commercial health and dental insurance data, which are the type in the FAIR Health Database, are based on charge amounts billed by healthcare 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 in different geographic areas. These fees are similar to what health insurance plans may call “usual, customary and reasonable” (UCR) charges. 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. Medicare fees are usually lower than commercial charge amounts.
The FH Medical Cost Lookup provides out-of-pocket cost estimates for individuals covered by plans that use either UCR-based or Medicare-based out-of-network reimbursement methods. Also see Medicare. The data available on the FH Consumer Cost Lookup reflect fees for services provided “out-of-network,” and not the “in-network” fees negotiated by insurers for services obtained from providers who participate in the plan’s network.
The amounts that health insurance companies will pay to healthcare providers in their networks for services. These rates are negotiated and established in the insurers’ contracts with in-network providers.
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.
A requirement that insured patients pay a portion of their medical costs, either as a deductible, or a flat dollar co-payment, or as co-insurance (i.e., a percentage of the total paid claim for a covered benefit or service).
The medical services, procedures, prescription drugs and other healthcare services that your insurer pays for under your plan. Keep in mind that not all care is covered. For instance, some plans will not pay for medications that are available over the counter. And, even if a service is covered, you may still need to pay a co-payment or co-insurance, request pre-authorization, or get a referral from your primary care physician before your insurer will pay. Your policy should contain a detailed list of what is and is not covered.
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 the plan will pay the provider.
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.
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.
Involve creating a restoration in a laboratory setting. Cast restorations cannot be done in the mouth due to the intense heat required to work with gold, titanium or porcelain materials, which are typically used for cast restorations. Gold or ceramic crowns, inlays and onlays are all types of cast restorations.
the removal of plaque and tartar from the visible surfaces of the teeth to prevent cavities, gingivitis, and gum disease. Usually tartar and plaque are removed from the crown portion of the tooth.
an evaluation by a dental professional who is not treating the patient to provide information on the presence of disease, compromised function and potential treatment options.
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 and are often used to improve the strength or appearance of teeth. Crowns are used to replace missing teeth by providing support for a bridge or partial denture (also known as prosthetic crowns). When these crowns are placed on an implant, they are called implant crowns. Crowns are usually made in a laboratory and are bonded to the tooth using dental cement.
A test to find cancer before a patient shows any symptoms, when treatment is likely to work best. Breast, cervical, and colorectal (colon) screenings are the most common types.
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 carpal tunnel surgery, ligaments are cut to relieve pressure on the median nerve.
Is performed to remove cataracts, which are painless, cloudy areas in the lens of the eye that can interfere with vision.
(also called a C-section); a procedure whereby the baby is delivered through an incision in the mother's abdomen.
A treatment that uses drugs to kill cancer cells or prevent them from multiplying.
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.
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.
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.
A common condition in which the cavities around the nasal passages (sinuses) become swollen for at least 12 weeks, despite attempts to treat them.
A lung disease that makes it hard to breathe, and gets worse over time. Chronic bronchitis and emphysema are types of COPD.
A visual exam of the large intestine (rectum and colon) performed with a flexible fiber optic scope. Colonoscopies can be performed as a screening test for colon cancer, and may be used to diagnose and treat other conditions.
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.
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.
A laboratory test that examines a sample of blood, urine, skin or other tissue to look for potential causes of infection or disease
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.
A fixed dollar amount of healthcare costs that you must pay before your insurer will consider payment for a healthcare 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.
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 and 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 that oversee the Patient Protection and Affordable Care Act.
Equipment which meets the following criteria: (a) can withstand repeated use; (b) is primarily and customarily used to serve a medical purpose; (c) generally, is not useful to a person in the absence of illness/injury; and (d) is appropriate for home use.
Is a process that involves repairing a tooth by removing the part of the tooth that is diseased (decayed). After the diseased 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) or a composite (white).
are prosthetic teeth that replace multiple (or all) missing teeth in an arch. Dentures, which are supported by the surrounding soft and hard tissues of the mouth, 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.
A mood disorder that causes a lasting feeling of sadness and loss of interest.
A bone density test that uses an x-ray to evaluate bone strength.
A chronic, or ongoing, disease associated with unusually high levels of sugar (glucose) in the blood.
Surgical procedures typically performed at the same time to open and widen (dilate) the cervix, and to scrape to remove the uterus lining (curettage).
Medical equipment you use at home and that can withstand repeated use (i.e., not disposable items). DME is primarily and customarily used for medical purposes by a person with an illness/injury. Wheelchairs, crutches and oxygen tanks are all durable medical equipment.
Services provided to treat an unexpected serious illness or injury that needs immediate medical attention.
is a U.S. Act of Congress passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA). It requires hospitals and ambulance services to provide care to anyone needing emergency healthcare treatment regardless of citizenship, legal status or ability to pay. There are no reimbursement provisions. As a result of the act, patients needing emergency treatment can be discharged only under their own informed consent or when their condition requires transfer to a hospital better equipped to administer the treatment.
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.
A law that sets standards and protections for most employee health insurance and pension plans.
State health insurance “marketplaces” whose establishment was mandated by the Patient Protection and Affordable Care Act. Exchanges are to be established by 2014 for individuals and small employer groups (exchanges for small employers are known as SHOP exchanges). Exchanges are responsible for calculating premium subsidies, enrollment, quality oversight, certification of qualified health plans that can be sold in the exchange, and other matters. By standardizing health insurance products, enrollment, operations, and oversight, exchanges are also meant to make the process of selecting insurance easier and transparent.
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 often allows members to see specialists without first obtaining a referral from a primary care doctor; these specialist visits are covered as long as the providers are in the network.
an unproven therapy which may or may not be better than the current standard therapy.
Your insurer will provide you with an EOB after you have submitted a healthcare claim to your insurer or after a provider has submitted a claim to your insurer on your behalf. The EOB will include a detailed explanation of how your insurer/administrator determined the amount of reimbursement it made to your provider or to you for a particular medical service. The EOB will also include information on how to appeal or challenge your insurer’s reimbursement decision. Note that you may not receive an EOB for care that you have received from a provider or facility that is in your insurer’s network if there is no required payment from you for those services.
a dental specialty that focuses on diseases of the tooth pulp (nerve tissue) and the tissues surrounding the root of a tooth.
procedures which help teeth grow (erupt) into the oral cavity and usually involve the removal both soft and hard tissue located just over the tooth crown that can block the emergence of the tooth.
a procedure including a visual assessment and other diagnostic aids, such as x-rays, to assess the health/condition of the teeth and soft and hard tissues of the mouth so that the appropriate dental care provided.
The removal of one or more teeth, or parts of teeth, from the jaw and soft tissue. Extractions are typically considered a surgical procedure.
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 stimulators and supplies are used for managing pain and wound healing.
A visual exam using a flexible fiber optic 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.
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.
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.
A national, independent, not-for-profit corporation whose mission is to bring transparency to healthcare costs and health insurance information.
See Dental Filling (Dental Restoration)
the delivery of fluoride (in the form of gel, varnish or mouth rinse) to the tooth surface to prevent tooth decay.
A hernia that forms between the abdomen and thigh.
A benign (non-cancerous) lump or tumor, located in the muscle of the uterus (a women’s womb).
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.
sedation of a patient during a surgical procedure. Anesthesia makes the patient unconscious so that s/he does not react to pain during the procedure.
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.
A common eye disease in which the fluid pressure inside the eye rises to an unhealthy level. If untreated, it may damage the optic nerve, causing vision loss or even blindness.
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.
A federal law that protects the privacy of individuals’ health information, regulates health insurance portability and non-discrimination, and provides health insurance simplification. The HIPAA provisions have been broadly expanded by the Patient Protection and Affordable Care Act.
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.
An HSA is a tax-advantaged savings account that a member can open to pay for qualified medical 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 Web site.) (See the Internal Revenue Service's list of qualified medical and dental expenses.)
There are two main types of HCPCS codes: Level I and Level II codes.
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.
A website maintained by the Office of Consumer Information and Insurance Oversight of the Department of Health and Human Services that provides information to consumers on available insurance options, data on care quality, and resources for disease prevention.
See Department of Health and Human Services.
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.
See Health Insurance Portability and Accountability Act.
Procedures that remove or reshape bone from the oral cavity (mouth), which are usually performed to remove diseased tissue, or for cosmetic reasons.
The death of heart muscle due to the loss of blood supply. The loss of blood supply is usually caused by a complete blockage of a coronary artery, one of the arteries that supplies blood to the heart muscle.
Surgery to remove hemorrhoids, which are swollen veins in the anal area that can bleed or be painful.
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.
A surgical procedure in which the hip joint is replaced by an artificial part.
A procedure in which the surgeon removes an artificial hip joint, or prosthesis, and replaces it with a new one.
Surgery to remove a woman's uterus.
Pertains to treatment from doctors, clinics, health centers, hospitals, medical practices and other providers with whom your plan has an agreement to provide care for its members. Usually, you will pay less out of your own pocket when you receive treatment from in-network providers.
The most money 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%).
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.
occurs when a tooth that has not fully moved into its expected position in the jaw. Impaction might occur for several reasons, such as lack of room in the jaw to accommodate the tooth, the tooth's growth path is obstructed by other teeth, or because the angle of the impacted tooth is not straight. The most common impacted teeth are 3rd molars or wisdom teeth.
the crown or appliance is placed directly onto the implant.
Devices that help stabilize multiple implants within the same arch to support a bridge or a denture. A metal bar may be used to connect the implants to add stability and support.
titanium rods that are surgically placed within the bone (endosseous implants) 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.
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.
a needle that releases a drug into a patient’s bloodstream. 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 through injections.
Cast (gold or ceramic) restorations that fit within the crown of the tooth are used in place of amalgam or composite restorations (fillings). They offer greater structural integrity and strength to the tooth. Inlays can be used to restore function to a tooth (restorative inlay) or to help replace a missing tooth (prosthetic inlay).
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.
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.
Incontinence and ostomy supplies are medical devices that are used for collecting urine and waste materials.
A hernia that forms in the groin area.
Intravenous (“within a vein”) infusions refer to the administration of fluids and drugs through a needle or tube which is inserted directly into a vein.
A surgical technique that can diagnose and treat problems in the knee joint. During the procedure, the surgeon will make a very small incision and insert a tiny camera — called an arthroscope — into the knee.
A surgical procedure in which parts of the knee joint are replaced with artificial parts.
A procedure in which a surgeon removes some or all of the parts of an original prosthesis or artificial knee joint that had been implanted during a knee replacement, and replaces them with new ones. Over time a knee replacement may fail for a variety of reasons. When this occurs, your knee can become painful and swollen. It may also feel stiff or unstable, making it difficult to perform your everyday activities. If your knee replacement fails, your doctor may recommend that you have a second surgery—revision total knee replacement
The total amount of money that a plan will pay for a member during their lifetime. As part of the Affordable Care Act (ACA), most health plans cannot impose lifetime maximums for “essential health benefits” like maternity care, hospital stays or prescription drugs. Dental plans may impose lifetime maximums.
Pain, muscle tension, or stiffness in the lower back area. It is defined as “chronic” when it lasts for 12 weeks or more.
This procedure removes tumors and small portions of the surrounding healthy tissue while conserving the breast. Implants are used in breast reconstruction or augmentation.
A low-dose x-ray of breast tissue that is often used to screen and diagnose abnormal growths in the breast.
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.
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.
Surgery to remove uterine fibroids, which leaves the uterus in place.
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.
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 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.
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.
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.
A person who qualifies for health coverage and is covered by a health plan. Also called an enrollee or participant.
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.
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 grinding (bruxing).
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.
Costs for medical treatment that your insurer does not cover. In some cases the service is a covered service, but the insurer’s reimbursement does not cover the entire charge amount. In these cases, you will be responsible for any charge not covered by your plan. In some cases the service itself is not covered by your plan and you will be responsible for the full charge. You may wish to call your insurer or consult your health insurance policy to determine whether certain services are included in your plan before you receive those services from your doctor.
Medical services that are not included in your plan. If you receive non-covered services, your health plan will not reimburse for those services and your provider will bill you, and you will be responsible for the full cost. You will need to consult with your health insurer, but generally payments you make for these services do not count toward your deductible. Make sure you know what services are covered before you visit your doctor.
a gas (N2O) that is given to a patient to inhale, to help reduce anxiety when getting dental treatment.
See Affordable Care Act (ACA).
The time of year when people can join a private health plan. This period usually happens a few weeks before the new coverage year begins. For example, if your health plan coverage runs from January 1 through December 31, open enrollment might be in November. The open enrollment period to sign up for the Affordable Care Act’s state Marketplaces usually runs from November 1 through January 31.
You can also qualify for a Special Enrollment Period outside that time if you lose your coverage, have a baby, get married, or go through other life changes. You can apply for and join government programs like Medicaid or the Children's Health Insurance Program (CHIP) any time of year. There are special open enrollment periods for Medicare, the program for people over 65 and those receiving Social Security Disability, depending on when you qualify for the program and the type of coverage you are enrolling in.
Pertains to treatment from doctors, clinics, health centers, hospitals, medical practices and other providers that do not have an agreement with your health 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.
Benefit plan coverage for services provided by doctors and other healthcare professionals who are not under a contract with your health plan.
Portion of the cost of healthcare services that the plan member must pay. This cost includes the difference between the amount charged by an out-of-network provider and what a health plan reimburses for such services.
The limit on the total amount a health insurance company requires a member to pay in deductible and co-insurance in a year. After reaching an out-of-pocket maximum, a member no longer pays co-insurance because the plan will begin to pay 100% of medical 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-pocked maximum for covered expenses. Members also continue to pay their monthly premiums to maintain their health insurance policies.
a mouth guard that is placed inside the mouth on the teeth to help protect teeth from the effects of grinding (bruxing).
dental visits that do not involve performing a specific dental procedure. Since a specific dental procedure, associated with an ADA procedure code (also known as a CDT code) is not performed, the time spent in the office is billed as an office visit. When a specific procedure is performed, the CDT is billed -- not the office visit.
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. Similar to crowns, onlays are 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.
Orthotics are medical devices that are used for treatment of the neuromuscular and skeletal system.
The medical specialty that deals with the treatment of the musculoskeletal system, including bones, joints, muscles, ligaments and tendons.
Degeneration of joint cartilage and the underlying bone, most common from middle age onward. It causes pain and stiffness, especially in the hip, knee, and thumb joints.
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.
The formal name of the health reform law enacted in 2010.
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.
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.
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.
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.
A process that your health plan or insurer goes through to make a decision that particular healthcare services, treatment plans, prescription drugs or durable medical equipment prescribed by your doctor are covered and medically necessary. Your plan may require preauthorization for certain services, such as hospitalization, before you receive them. Preauthorization requirements are generally waived if you need emergency care.
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.
The amount a consumer (or employer) pays to a health insurance company for health coverage. The health insurance company generally recalculates the premium each policy year. This amount is usually paid in monthly installments. When a consumer receives health 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.
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.
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.
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.
Doctors and other healthcare professionals who agree to provide medical care to members of a health plan, under the terms of a contract.
Under the ACA, 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.
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.
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.
dental surgeries performed on the supporting tissues of the teeth to remove, reshape or add (graft) bone to restore function to the area. These surgeries help correct defects in the bone, which are often caused by periodontal disease.
The period following periodontal therapy (active treatment such as scaling and root planing) when the dentist tracks the results of periodontal therapy and identifies areas that may need additional treatment. Maintenance may consist of the removal of plaque and calculus, local scaling and root planing, x-rays when appropriate and other procedures based on the patient’s response to the initial therapy.
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.
Dental surgical services that involve only the soft tissue in the mouth that surround the teeth. These surgeries help correct defects, many of which were caused by periodontal disease. These surgeries can include the removal of diseased tissue, reshaping tissue or the adding (grafting) tissue into an area to help improve function and appearance.
A procedure that attaches weak, loose teeth together, 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.
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 hold the filling in place.
False teeth that are used to replace missing teeth. They can be made from gold, porcelain, or other materials. They are typically used as part of a bridge.
These restorations follow root canal treatment and are placed inside the tooth, within the pulp chamber. 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.
A fixed or removable dental appliance used to replace one or more lost or missing natural teeth in an arch.
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 (talking & eating) by the patient for several days to identify areas that should be adjusted.
Nerves and blood vessels that are located in the middle of the tooth and conduct sensations such as pain and hot/cold temperature.
A procedure to place a medicated dressing or cement 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.
A procedure performed to help determine the health of the tooth. If the tooth does not respond to pulp test stimulation, the tooth may not be healthy and may require dental work. The pulp test is typically combined with other diagnostic procedures before a final treatment decision is made.
Treatments that are applied to pulp tissue, usually involving endodontic treatment, such as root canals.
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.
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.
Lung inflammation caused by a bacterial or viral infection, in which the air sacs in the lungs fill with pus and may become solid.
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.
A disease in which cells in the prostate gland become abnormal and start to grow uncontrollably, forming tumors.
A blood test that measures levels of prostate-specific antigen (PSA). High levels of PSA may be a sign of prostate cancer.
Qualified medical 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 medical expenses and other expenses permitted to be reimbursed from health savings accounts (HSAs) include, but are not limited to, the following:
A medical 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.
The amount that your insurer pays for a specific service. For instance, your insurer’s reimbursement rate for a primary care visit may be up to $80. If your provider charges $100, you would be responsible for the remaining $20 if your plan covers that service at 100% of the maximum fee.
A process that involves refitting either a complete or partial denture in the mouth by replacing the denture base material (acrylic). This process usually does not typically replace the teeth.
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.
a naturally occurring space within a tooth that consists of the pulp chamber (within the crown of the tooth), and the canal(s) (spaces) from the crown of the tooth to the apex (tip) of the root that contain the blood and nerve supply for 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.
A process that removes or eliminates dental plaque and calculus (where bacteria live) on the root surface of the tooth.
A type of therapy used to destroy cancer cells and other diseases with high-energy particles.
Respirator and oxygen equipment are used by people who have difficulty breathing.
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.
The removal or elimination of dental plaque and calculus (where bacteria live) on the tooth.
Thin plastic coatings, typically used for children, which 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.
The use of pharmacological agents to calm and relax a patient prior to and during a dental appointment. The pharmacological agents usually belong to a class of drugs called sedatives, which act by depressing the central nervous system, specifically those areas that control conscious awareness.
A temporary restoration placed on a tooth to 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.
A procedure that removes soft tissue that is diseased or impedes the normal function of the mouth.
Metal or plastic appliances that help save space for permanent teeth when baby teeth (usually back teeth) are lost prematurely.
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.
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.
Procedures which help correct a diseased or defected area.
Sleep apnea devices are used to increase airflow to the lungs.
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.
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.
The sudden death of brain cells due to lack of oxygen, caused by blockage of blood flow or tearing of an artery to the brain. Symptoms may include sudden loss of speech, weakness, or paralysis of one side of the body.
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.
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.
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.
A process where 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.
Surgery to remove the tonsils, which are glands located at the back of the throat.
Surgery to remove the part of the prostate gland that is blocking the flow of urine.
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 bill.
Also referred to as a sonogram, this test uses sound waves to create images of the inside of the body.
A procedure that lets your doctor look at the inside lining of the esophagus, stomach, and the first part of the small intestine (duodenum). A thin, flexible viewing tool called an endoscope (scope) is used.
A general term used to describe short-term infections involving the nose, paranasal sinuses, pharynx (the cavity behind the nose and mouth), larynx (voice box), trachea, and bronchi.
An infection of the kidney, ureter (the duct connecting the kidneys and bladder), bladder, or urethra.
The birth of a baby through the vagina.
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. Once created, all veneers are bonded to the tooth, typically using a resin cement. In contrast, a porcelain veneer may only be produced in a lab and then bonded to the tooth.
The surgical preparation of the alveolar ridge (jaw bone where the teeth are located) generally involving increasing the spacing of the region 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. Surgery can extend anywhere from the outside of the teeth and gums to the inside of the cheeks.
The third and last molars on each side of the upper and lower jaws. They are the final teeth to come in; usually in your late teens or early twenties. Since wisdom teeth come in late, they may not fit in the mouth. This can lead to wisdom teeth that are impacted (below the gum line, not fully erupted into the mouth). Impacted teeth can cause swelling and pain, and may need to be removed.
Wound care supplies are used for improving the healing of a wound.
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
Uses small electromagnetic radiation to take pictures of the body.
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