Important Dental Claim Terminology

Don’t know the difference between “disallow and deny”?   It is confusing sometimes to be able to distinguish what is the practice’s right to collect.

Here are a few definitions to clarify dental insurance talk.

ALLOWABLE: The amount used to calculate the appropriate benefit allowance consistent with “Maximum Allowed Amount.”

ALTERNATE BENEFIT: In cases where alternative methods of treatment exist, benefits are provided for the least costly professionally accepted treatment. This determination is not intended to reflect negatively on the dentist’s treatment plan or to recommend which treatment should be provided. It is a determination of benefits under terms of the Patient’s coverage. The dentist and Patient should decide the course of treatment. If the treatment rendered is other than the one Benefited the difference between allowance and the dentist charge for the actual treatment rendered is collectible from the Patient.

BENEFITED: Processed for payment subject to the Patient’s dental benefit contract stipulations including but not limited to copayments, deductibles, maximums, determination of the Allowable amount, etc.

BY REPORT AND SUBJECT TO COVERAGE UNDER MEDICAL: When a procedure is By Report and Subject to Coverage Under Medical, it should be submitted to the Patient’s medical carrier first. When submitting, include a copy of the explanation of payment or payment voucher from the medical carrier with the claim, plus a narrative describing the procedure performed, reasons for performing the procedure, pathology report if appropriate, and any other information deemed pertinent. In the absence of such information the procedure will not be Benefited.

DENIED: If the fee for a procedure is Denied, the fee charged is not payable and is chargeable to the Patient.

DISALLOW/DISALLOWED: If the fee for a procedure is Disallowed, it is not Benefited and is not collectible from the Patient by a contracting dentist.

IN CONJUNCTION WITH: A service which is considered part of another procedure or episode of treatment, including but not limited to services being rendered on the same day.

PROCESSED AS: When a procedure is Processed As a different procedure, contracting dentists agree to accept all the limitations, claims guidelines, and Allowable amounts that apply to the procedure that is Benefited by the Patient’s dental benefit contract