Glossary

Dental billing glossary

104 terms every dental front office runs into — codes, benefits, AR, credentialing, and payer types — defined in plain English, without the jargon-to-explain-the-jargon.

Claims & coding

CDT code: Current Dental Terminology codes — the ADA's standardized codes for every dental procedure. Every dental claim is built on them, and they are updated annually.
CPT code: Current Procedural Terminology codes — the medical procedure codes used when a dental service (like a surgical extraction) is billed to medical insurance instead of dental.
ICD-10: The diagnosis code set that accompanies CPT codes on a medical claim, describing why a procedure was medically necessary.
Clean claim: A claim submitted with complete, accurate information and no errors, so the payer can process it without asking for more. A clean-claim rate in the high 90s is the goal.
Claim scrubbing: Reviewing a claim for coding errors, missing attachments, and eligibility problems before it is submitted — catching denials before the payer does.
Clearinghouse: An intermediary that receives claims from a practice, checks them, and routes them to the correct payer electronically.
Attachment / narrative: Supporting documentation — an X-ray, perio chart, or written narrative — that a payer requires to approve certain procedures like crowns or periodontal treatment.
Downgrade: When a payer reimburses a procedure at the rate of a cheaper alternative — for example, paying a tooth-colored composite filling at the amalgam (silver) rate.
Bundling: When a payer combines two separately billed procedures into one and pays less than if each were reimbursed on its own.
Adjudication: The payer’s process of reviewing a submitted claim and deciding what, if anything, it will pay.
Cross-coding: Translating a dental (CDT) procedure into the medical (CPT/ICD-10) codes needed to bill it to medical insurance — common for surgical extractions, sleep appliances, and CBCT imaging.
Medical necessity: Documentation showing a procedure was needed to diagnose or treat a condition — the standard a medical payer applies before it will cover a dental service.
Unbundling: Billing procedures separately that a payer expects reported under a single code; the opposite of bundling, and a common audit flag.
Electronic attachment (NEA / FastAttach): A service that sends X-rays, perio charts, and narratives to payers electronically with a claim, replacing mailed paper attachments.
Modifier: A code added to a procedure to give the payer more detail — for example, that a service was distinct or performed on a specific tooth or quadrant.
ADA Dental Claim Form: The standardized claim form maintained by the American Dental Association that dental claims are submitted on, in paper or electronic form.
Superbill: An itemized summary of the services a patient received, sometimes given to patients so they can file their own out-of-network claim.

Insurance & benefits

Eligibility: Confirmation that a patient's insurance coverage is active on the date of service — the first thing verification checks.
Annual maximum: The most a dental plan will pay toward a patient’s care in a benefit year; once it is reached, the patient pays out of pocket.
Deductible: The amount a patient must pay before their plan begins to contribute, usually per benefit year.
Coinsurance: The percentage of a covered procedure the plan pays — commonly 100% preventive, 80% basic, 50% major — with the patient responsible for the rest.
Frequency limitation: A cap on how often a plan covers a service, such as two cleanings or one set of bitewing X-rays per year.
Waiting period: A span of time after a plan starts before certain services (often major or orthodontic) are covered.
Missing tooth clause: A plan provision that excludes coverage for replacing a tooth that was already missing before the policy began.
Coordination of benefits (COB): The rules that determine which plan pays first when a patient is covered by more than one insurance.
Pre-authorization: A payer’s advance approval that a proposed procedure will be covered — often required for crowns, implants, ortho, and surgery.
270 / 271 eligibility transaction: The standardized electronic request (270) and response (271) used to check a patient’s insurance eligibility.
Least Expensive Alternative Treatment (LEAT): A plan clause that pays only for the cheapest clinically acceptable option — for example, reimbursing a crown at the price of a large filling.
Alternate benefit: The payer’s decision to cover a lower-cost alternative to the treatment performed, leaving the patient responsible for the difference.
Non-covered service: A procedure a plan does not pay for at all; the patient is responsible for the full contracted fee.
Assignment of benefits: A patient’s authorization for the insurer to pay the dentist directly instead of reimbursing the patient.
Balance billing: Billing a patient for the difference between the provider’s fee and the amount an out-of-network plan allowed.
Benefit year: The 12-month period a plan uses to track deductibles and annual maximums — often the calendar year, but not always.

Payments & posting

EOB (Explanation of Benefits): The statement a payer sends explaining how a claim was processed — what was paid, adjusted, denied, and left to the patient.
ERA (Electronic Remittance Advice): The electronic version of an EOB, delivered directly into the practice’s software so payments can be posted without paper.
EFT (Electronic Funds Transfer): Direct deposit of insurance payments into the practice’s bank account, replacing mailed paper checks.
Payment posting: Recording each insurance and patient payment against the correct claim, and reconciling it against what was expected.
Write-off: The portion of a billed amount the practice agrees not to collect — often the difference between the full fee and the contracted rate.
Allowed amount: The maximum a payer will reimburse for a procedure under its contract, regardless of the practice’s full fee.
Underpayment: When a payer reimburses less than the contracted allowed amount — easy to miss unless the EOB is reconciled against the fee schedule.
Fee schedule: The list of contracted reimbursement rates a payer will pay a practice for each procedure code.
UCR (Usual, Customary, and Reasonable): A payer’s benchmark for typical fees in a geographic area, used to set out-of-network reimbursement.
Contractual adjustment: The write-off of the difference between a practice’s full fee and the payer’s contracted allowed amount, required by the in-network agreement.
Virtual credit card (VCC): A single-use card number some payers issue as payment instead of EFT or a check — convenient for the payer, but it often carries processing fees for the practice.
Credit balance: A negative balance on an account when a patient or payer has paid more than was owed, usually requiring a refund.
Overpayment: When a payer or patient pays more than the allowed or owed amount — must be identified and refunded or reconciled.
Remittance: The payment and accompanying explanation a payer sends for a batch of claims, delivered electronically as an ERA.

AR & collections

Accounts receivable (AR): Money owed to the practice for services already provided — by insurers and by patients.
Aging report: A breakdown of outstanding AR by how long it has been unpaid — the 0–30, 31–60, 61–90, and 90+ day buckets.
Days in AR: The average number of days it takes the practice to collect a dollar of production; a common target is under 30.
Net collection rate: The share of collectible production a practice actually collects after contractual adjustments; 95%+ is healthy.
Gross collection rate: The share of total billed charges collected, before adjustments — less meaningful than net collection rate.
Timely filing: The deadline by which a claim must reach the payer to be considered — often as short as 90 days from the date of service.
Denial: A payer’s decision not to pay a claim, in whole or part, for reasons like missing information, eligibility, or coding.
Appeal: A formal request asking a payer to reconsider a denied claim, with the documentation that supports payment.
Patient responsibility: The portion of a bill the patient owes — deductible, coinsurance, and any non-covered amounts.
Recoupment: When a payer reclaims money it previously paid, often after an audit or overpayment, by offsetting future payments.
Insurance AR vs patient AR: The split of outstanding balances between what insurers still owe and what patients owe — each worked with a different process and cadence.
Denial code (CARC / RARC): Standardized reason codes on a remittance that explain why a claim was adjusted or denied and what, if anything, to do next.
Rework: Correcting and resubmitting a denied or rejected claim so it can be paid, ideally before the timely-filing window closes.
Bad debt: A patient balance the practice has decided it is unlikely to collect and writes off — distinct from a contractual adjustment.
Patient statement: The bill sent to a patient showing the balance they owe after insurance has paid.

Credentialing

Credentialing: The process of getting a provider approved to bill and be reimbursed by an insurance payer.
Re-credentialing: The periodic renewal of a provider’s credentials with a payer, typically every three years.
CAQH: A shared online profile (Council for Affordable Quality Healthcare) payers pull provider information from during credentialing; it must be kept current and re-attested.
NPI (National Provider Identifier): A unique 10-digit number identifying a healthcare provider on claims and enrollments.
Primary source verification (PSV): The payer’s step of confirming a provider’s license, education, and credentials directly with the issuing sources.
Provider enrollment: Registering a provider with a payer or a Medicaid program so the practice can submit claims and be paid.
In-network: A provider who has a contract with a payer, agreeing to its fee schedule in exchange for patient volume.
Out-of-network: A provider without a contract with a given payer; patients typically pay more and reimbursement differs.
Effective date: The date a provider’s credentialing takes effect and the practice can begin billing that payer in-network.
Revalidation: Medicaid’s version of re-credentialing — periodically re-verifying a provider’s enrollment to stay active.
DEA number: A registration number from the Drug Enforcement Administration that lets a provider prescribe controlled substances; often required on enrollments.
Taxonomy code: A code identifying a provider’s specialty and type, used on claims and enrollments to classify the provider.
PECOS: The Medicare online system (Provider Enrollment, Chain and Ownership System) used to enroll and manage Medicare provider information.
Group NPI: The organization-level National Provider Identifier a practice bills under, distinct from each individual provider’s NPI.
Delegated credentialing: An arrangement where a payer lets a qualified group or DSO credential its own providers, speeding the process.

Plan & payer types

PPO (Preferred Provider Organization): A dental plan that reimburses more when patients see in-network providers but allows out-of-network care at a lower rate.
DHMO / DMO: A dental HMO that assigns patients to a network dentist and pays providers a set amount per patient (capitation) rather than per procedure.
Indemnity plan: A traditional plan that pays a percentage of the dentist’s fee with few network restrictions; increasingly rare.
Medicaid: The joint federal-state program covering dental care for eligible low-income patients; coverage, rules, and administration vary by state.
CHIP: Children's Health Insurance Program — state-federal coverage for children in families that earn too much for Medicaid but need help affording care.
Medicare Advantage (dental): Private Medicare plans that often include a dental benefit, distinct from Original Medicare, which generally does not cover routine dental.
Capitation: A payment model where a plan pays a provider a fixed amount per enrolled patient per month, regardless of services used — common in DHMOs.
EPSDT: Early and Periodic Screening, Diagnostic and Treatment — the Medicaid benefit guaranteeing comprehensive dental care for children.
Dual coverage: When a patient is covered by two dental plans, requiring coordination of benefits to determine who pays first.
Carve-out: When a benefit like dental is separated from a broader plan and administered by a different company — common in state Medicaid dental programs.
Third-party administrator (TPA): A company that processes claims and administers benefits for a self-funded employer plan, rather than insuring the risk itself.
Discount dental plan: Not insurance — a membership that gives patients reduced fees at participating dentists in exchange for an annual fee.
Self-funded plan: An employer plan where the employer pays claims directly, often via a TPA, instead of buying insurance; governed by federal ERISA rules.
Network leasing: When one payer rents access to another network’s contracted providers and fee schedules, so a plan you never joined may still route claims to you.

Front office & practice operations

Practice management system (PMS): The software a dental office runs on — scheduling, charting, ledgers, and claims — such as Open Dental, Dentrix, or Eaglesoft.
Recall / recare: The system for bringing patients back for routine hygiene and exams on schedule; a major driver of production.
Treatment plan estimate: A pre-treatment breakdown of what insurance is expected to pay and what the patient will owe, used when presenting care.
Production: The dollar value of the dentistry performed, before adjustments or collections — what the practice did.
Collections: The money actually received against production — what the practice kept; the gap between the two is where revenue leaks.
Case acceptance rate: The share of proposed treatment patients agree to and schedule — closely tied to how clearly costs are presented.
No-show: A patient who misses an appointment without canceling, leaving unrecoverable chair time; reducing no-shows protects production.

Compliance & regulatory

HIPAA: The federal law setting privacy and security rules for protected health information, which every billing workflow must follow.
PHI (Protected Health Information): Any patient-identifiable health or billing information protected under HIPAA.
Business Associate Agreement (BAA): A HIPAA-required contract between a practice and any vendor — like a billing company — that handles PHI on its behalf.
Fraud, waste & abuse: Improper billing practices — from intentional fraud to careless errors — that payers and regulators audit for and penalize.
Payer audit: A payer’s review of a practice’s claims and documentation to confirm services were provided and billed correctly; can lead to recoupment.
TIN (Tax Identification Number): The IRS number a practice bills under, tied to payments and 1099 reporting, and matched to the group NPI on enrollments.

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