Insurance Glossary

When a dentist charges the member for costs above the dental plan's allowable amount, it is often referred to as balance billing. Generally, a dental plan's allowable amount for services from in-network dentists equals the fees that these dentists agree to accept when joining a dental plan administrator's network. Because in-network dentists must accept these contracted fees as payment in full, balance billing the member for the difference between the allowable amount and the dentist's usual charge is not allowed. When a member visits an out-of-network dentist, the dental plan's allowable amount may be less than the dentist's charge. When this happens, out-of-network dentists may balance bill members for the difference.

This is the amount paid by a dental plan sponsor or administrator for covered dental services. The benefit may be paid to the dental plan member or directly to the dentist if the dental plan member has assigned their benefits to the dentist.

This is the payment that a dental plan administrator makes to a dental plan member, or to a dentist on behalf of a dental plan member.

Related articles

• Why Choose a Network Dentist?

When parents or guardians each cover their dependents on their dental plan, dental plan administrators use a Coordination of Benefits provision called the birthday rule to determine which dental plan should be the primary and secondary dental plan (i.e. which dental plan pays benefits first). The birthday rule stipulates that the parent or guardian whose date of birth falls first in a calendar year regardless of age is considered the primary payor. You should read your dental plan documents or consult with an HR or benefits consultant for a full understanding of how the provision is applied.