Glossary/Definition of Terms

The following are definitions of words that have special or technical meanings under the AARP® Dental Insurance Plan, administered by Delta Dental Insurance Company.

Delta Dental DPO Terms

Abscess
A localized infection formed at the apex of the root tip.
Abutment
A tooth, a root, or an implant used for the retention of a fixed or removable prosthesis. Also known as a retainer.
Accepted Fee
The amount the attending Provider agrees to accept as payment in full for services rendered.
Amalgam
Sometimes referred to as a silver filling. Used for more than a century, amalgam fillings are proven to be safe, cost-effective and durable.
Anterior Teeth
The teeth toward the front, which include the incisors and cuspids.
Apex
The anatomic area at the end of the tooth root.
Apicoectomy
The surgical removal of the apical portion of the tooth through a surgical opening made in the overlying bone and gigival tissues.
Attrition
The wearing down of the surface of a tooth from chewing or grinding teeth.
Balance Billing
Balance billing occurs when a Provider bills an enrollee for any difference (or balance) between the Non-Delta Dental Provider Submitted Fee, the Premier Provider's Contracted Fee and the Maximum Contract Allowance. DPO Providers agree to accept the Maximum Contract Allowance as their full charge and will not bill Enrollees for the difference. Non-Delta Dental Providers are not limited in the amount they may balance a bill.
Benefits (In-Network or Out-of-Network)
The amounts that Delta Dental will pay for dental services under the Contract. In-Network Benefits are those covered by the Contract and performed by a DPO Provider. Out-of-Network Benefits are those covered by the Contract but performed by a Premier Provider or a Non-Delta Dental Provider.
Benefit Waiting Period
The 12-month period of time of continuous enrollment that an Enrollee must complete before certain dental procedures become covered benefits.
Bicuspids/Premolars
The teeth with two rounded points (cusps) located between the eye-teeth (cuspids) and the molars.
Bleaching
A technique that lightens the color of heavily stained teeth. Considered a cosmetic procedure.
Bonding
The technique to adhere a filling material to a tooth. Bonding materials may be used to repair chipped, cracked, misshapen or discolored teeth, or to fill in a gap between teeth.
Bridges
Non-removable artificial teeth attached to adjoining natural teeth when one or a few teeth are missing.
Bruxism
Involuntary clenching or grinding of the teeth.
Calendar Year
The time period beginning on January 1 and ending on December 31.
Caries
Tooth decay, also known as a cavity.
Cast Restorations
A procedure that uses a model of the tooth (an impression) to make a metal casting which replaces missing parts. Example: a crown.
Centrals/Laterals
The four front teeth. The centrals are the two upper and two lower teeth in the very center of your mouth. The laterals are the teeth just adjacent to the centrals.
Claim Form
The standard form used to file a claim or request a Pre-treatment Estimate.
Coinsurance Amount
Your share of the cost of a given service, usually expressed as a percentage of the Maximum Contract Allowance.
Contract
The agreement between Delta Dental and the Contract holder, including the application and any attachments.
Contract Benefit Level
The percentage of Maximum Contract Allowance that Delta Dental will pay after the Deductible has been satisfied.
Contracting Provider
A person who contracts with Delta Dental or any member of the Delta Dental Plans Association with which Delta Dental contracts and agrees to abide by certain administrative guidelines. Contracting Providers include Providers who are members of the Premier or DPO programs.
Covered Services
See Benefits.
Crown/Jacket/Cap
The artificial covering of a tooth with metal, porcelain or porcelain fused to metal. Crowns cover teeth weakened by decay or severely damaged or chipped.
Cusp
The pointed or rounded part of a tooth's biting surface.
Cuspids
The teeth near the front of the mouth that come to a single point.
Sometimes called the "eye teeth" or "canines."
Deciduous Teeth
Primary or baby teeth.
Deductible
The dollar amount Enrollees must pay toward completed treatment before Delta Dental payment is applied to those services in a Calendar Year.
Delta Dental Premier® Provider (Premier Provider)
A Provider who contracts with Delta Dental Insurance Company or any other member company of the Delta Dental Plans Association and agrees to accept the contracted fees as payment in full for services provided under a plan and complies with Delta Dental's administrative guidelines.
DPO
Dental Provider Organization.
DPO Provider's Contracted Fee
The fee for each Single Procedure that a DPO Provider has contractually agreed to accept as payment in full for treating Enrollees.
Dental Provider Organization (DPO) Plan
Delta Dental's plan that allows Enrollees to visit any licensed dentist, but offers incentives to choose a DPO Dentist.
Dentures
Removable artificial teeth in a plastic base that rests directly on the gums. A denture may be a complete or partial depending on the number of missing natural teeth.
DPO Provider (DPO Provider)
A Provider who contracts with Delta Dental Insurance Company or any other member company of the Delta Dental Plans Association and agrees to accept the contracted fees as payment in full for services provided under this DPO dental plan and complies with Delta Dental's administrative guidelines.
Effective Date
The date your eligibility for covered services begins. For the AARP Dental Insurance Plan, this date will always be the first of the month.
Endodontics
Dental services that involve treatment of diseases or injuries that affect the root tip or nerve of the tooth.
Enrollee
An Eligible Member or an Eligible Dependent enrolled to receive Benefits; may also be referred to as "Patient." There are two subsets of Enrollees: the Primary Enrollee who is the AARP member under whom the family is enrolled, and the enrolled family members including Spouse and eligible children.
Exclusions
Services that are not covered under the AARP Dental Insurance Plan. Explanation of Benefits (EOB): See Notice of Payment.
Gingivitis
An inflammation of the gums surrounding the teeth caused by a buildup of plaque or food particles.
Impacted Tooth
A tooth partially or fully beneath the gum tissue that is under bone or soft tissue and is unlikely to erupt (grow out) on its own.
Implant
A support for a bridge or denture that has been surgically placed into the bone.
Inlay
A solid laboratory-processed filling cast to fit the missing portion of the tooth and cemented into place. This type of restoration does not involve the high points (cusps) of the tooth.
Laminate Veneer
A thin plastic or porcelain shell applied to the front of a tooth to restore, strengthen or improve its appearance.
Limitations
The number of services allowed, frequency of services allowed, and the most affordable dentally appropriate service.
Malocclusion
Incorrect position of biting or chewing surfaces of the upper and lower teeth.
Maximum Benefit
The total maximum dollar amount the AARP Dental Insurance Plan will pay toward the cost of dental care incurred by an individual Enrollee in a Calendar Year.
Maximum Contract Allowance
The reimbursement under the Enrollee's benefit plan against which Delta Dental calculates its payment and the Enrollee's financial obligation. Subject to adjustment for extreme difficulty or unusual circumstances, the Maximum Contract Allowance for services provided:
Member
A person enrolled as a member of AARP and assigned an AARP membership number.
Molars
Teeth with broad chewing surface for grinding food, located in the back of the mouth.
Non-Contracting Provider/Non-Delta Dental Provider
A Provider who does not contract in either the Premier or DPO programs and who is not contractually bound to abide by Delta Dental's administrative guidelines.
Notice of Payment
The statement you receive after a claim is processed, detailing how your claim payment was calculated including the procedures and fees submitted and the amount for which you are responsible.
Occlusal
Pertaining to the biting surfaces of the premolar and molar teeth or contacting surfaces of opposing teeth. For example, the chewing surfaces of the back teeth.
Out-of-Pocket Costs
The portion of dental fees that you pay. Out-of-pocket costs include your deductible, coinsurance, any amount exceeding the Calendar Year Maximum Benefit amount, and optional services not covered by the AARP Dental Insurance Plan.
Overdenture
A removable denture that fits over a small number of remaining natural teeth or implants to provide better stability for the denture.
Patient Pays
Enrollee's financial obligation for services calculated as the difference between the amount shown as the Accepted Fee and the portion shown as "Delta Dental Pays" on the claims statement when a claim is processed.
Pedodontist/Pediatric Provider
A dental specialist who treats children from birth through adolescence.
Periapical
The area surrounding the end of a tooth root.
Periodontics
Services that involve treatment of diseases of the gums, tissue and bone that supports the teeth.
Periodontitis/Gum Disease
Chronic inflammation and destruction of supporting bone and tissue membrane around the roots of teeth.
Permanent Teeth
Adult teeth.
Plaque
A bacteria-containing substance that collects on the surface of teeth. Plaque can cause decay and gum irritation when it is not removed by daily brushing and flossing.
Pontic
The portion of a dental bridge that replaces missing teeth.
Post and Core
An anchor placed in the tooth root following a root canal to strengthen the tooth and help hold a crown (cap) in place.
Posterior Teeth
The teeth toward the back of the mouth.
Premiums
The money paid to Delta Dental for each month of dental coverage for the Primary Enrollee and the Primary Enrollee's enrolled family members. Payment may be submitted monthly (through EFT), quarterly, semi-annually, or annually.
Pre-treatment Estimate
An estimation of the allowable Benefits under this Contract for the services proposed, assuming the person is an eligible Enrollee.
Primary Enrollee
The AARP member who applies for enrollment in the AARP Dental Insurance Plan. At least one enrolled family member must be an active AARP member who will be designated as the Primary Enrollee.
Program
A collective expression for all Contracting Providers who have contracted with Delta Dental to offer services to enrollees and who have agreed to abide by certain administrative guidelines. There are two separate and distinct Delta Dental programs: Delta Dental Premier and DPO. Under the AARP Dental Insurance Plan, visiting a DPO Provider generally results in the lowest out-of-pocket costs.
Prophylaxis
A professional cleaning to remove plaque, calculus (mineralized plaque) and stains to help prevent dental disease.
Prosthodontics
Services involving replacement of missing teeth with artificial materials, such as a bridge or denture.
Provider
A person licensed to practice dentistry when and where services are performed. A Provider shall also include a dental partnership, dental professional corporation or dental clinic.
Pulp
The blood vessels and nerve tissue inside a tooth
Qualifying Status Change
A change in:
  • marital status (marriage, divorce, annulment or death);
  • number of dependents (a child's birth, adoption of a child, institution of a suit wherein the insured seeks to adopt a child, addition of a step or foster child or death of a child);
  • employment status (change in employment status of Enrollee, spouse or dependent child);
  • dependent child ceases to satisfy eligibility requirements (limiting age, student status or marital status);
  • residence (Enrollee, dependent spouse or child moves);
  • a court order requiring dependent coverage; or
  • any other current or future election changes permitted by IRC Section 125.
Resin/Composite
Tooth-colored filling material. Although cosmetically superior, it is less durable than other materials.
Restorations
Procedures involving the replacement of missing or damaged tooth structure with artificial materials
Root Canal Treatment
The removal of the pulp tissue of a tooth due to decay, infection (abscess) or injury.
Root Planing
A treatment of periodontal disease that involves scraping the roots of a tooth and gums to remove bacteria and mineralized plaque (tartar) from the root surfaces and tooth pocket.
Sealant
A think plastic material used to cover the biting surface of a child's tooth to prevent tooth decay.
Single Procedure
A dental procedure that is assigned a separate CDT® number.
Spouse
A person related to, a common law spouse or a partner of the Primary Enrollee as defined and as may be required to be treated as a Spouse by the laws of Texas.
Submitted Fee
The amount that the Provider bills and enters on a claim for a specific procedure.

DeltaCare USA DHMO Terms

Administrator
Delta Dental Insurance Company ("Delta Dental") or other entity designated by ALPHA, operating as an Administrator in the state of Texas. Certain functions described throughout this EOC may be performed by the Administrator, as designated by ALPHA. The mailing address for the Administrator is P.O. Box 1803, Alpharetta, Georgia 30023. The Administrator will answer calls directed to 1-877-522-9156.
Authorization
The process by which ALPHA determines if a procedure or treatment is a referable Benefit under the Enrollee's plan.
Benefits
Those dental services available under the terms of the Contract as specified in the Description of Benefits and Copayments.
Contract
The agreement between ALPHA and Contractholder including the Application for the Contract, the attached schedules, and any appendices, endorsements or riders. The Contract constitutes the entire agreement between the parties.
Contract Dentist
A Dentist who provides services in general dentistry and has agreed to provide Benefits to Enrollees under this Program.
Contractholder
AARP Dental Insurance Trust.
Contract Orthodontist
A Dentist who specializes in orthodontics and has agreed to provide Benefits to Enrollees under this Program.
Contract Specialty Care Dentist
A Dentist who provides Specialized Services and has agreed to provide Benefits to Enrollees under this Program.
Copayment
The amount charged to an Enrollee by a Dentist for the Benefits provided under this Program.
Dentist
A duly licensed Dentist legally entitled to practice dentistry at the time and in the state or jurisdiction in which services are performed.
Domestic Partner
A person who, together with the Eligible Member, has affirmed a domestic partnership.
Effective Date
The first day of the month following ALPHA's timely receipt of Premium and the completed and signed enrollment form.
Eligible Dependent
Any of the dependents of an Eligible Member who are eligible to enroll for Benefits and who meet the conditions of eligibility as described under Eligibility for Benefits.
Eligible Member
Any AARP member who has been assigned an AARP membership number and who meets the conditions of eligibility as described under Eligibility for Benefits.
Emergency Dental Services
Procedures administered in a Dentist's facility, emergency dental clinic or other comparable facility to evaluate and stabilize dental conditions of a recent onset and severity accomplished by excessive bleeding, severe pain or acute infection that would lead a prudent layperson possessing an average knowledge of dentistry to believe that immediate care is needed.
Enrollee
An Eligible Member ("Primary Enrollee") or an Eligible Dependent ("Dependent Enrollee") enrolled to receive Benefits.
Premium
The money paid by the Primary Enrollee to cover the Primary Enrollee and any Dependent Enrollee under this Program.
Primary Enrollee
The active AARP member who applies for enrollment in the Dental HMO Program for AARP Members.
Service Area: The State of Texas, except for the following counties:
Bailey, Brewster, Collingsworth, Concho, Culberson, Dallam, Edwards, Hall, Hansford, Hemphill, Jeff Davis, Kinney, Lipscomb, Loving, McCulloch, Menard, Motley, Ochiltree, Pecos, Presidio, Reeves, Roberts, Schleicher, Sherman, Sutton, Terrell, Tom Green, Val Verde, and Wheeler.
Specialized Services
Services performed by a Dentist who specializes in the practice of oral surgery, endodontics, periodontics or pediatric dentistry and which must be authorized by ALPHA.
Spouse
A spouse by lawful marriage.
We, Us and Our
ALPHA or the Administrator, as appropriate.

AARP Dental Insurance Plan

Delta Dental DPO plan is insured and administered by Delta Dental Insurance Company.

DeltaCare USA dental HMO plan is underwritten by Alpha Dental Programs, Inc., and administered by Delta Dental Insurance Company.

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