Blue Cross Blue Shield FEP Dental
Section 9 Definitions of Terms We Use in This Brochure
Section 9 Definitions of Terms We Use in This Brochure
Section 9 Definitions of Terms We Use in This Brochure
Alternative Benefit
If we determine a service less costly than the one performed by your dentist could have been performed by your dentist, we will pay benefits based upon the less costly services. See Section 3, How You Get Care.
Annual Benefit Maximum
The maximum annual benefit that you can receive per person.
Annuitants
Federal retirees (who retired on an immediate annuity) and survivors (of those who retired on an immediate annuity or died in service) receiving an annuity. This also includes those receiving compensation from the Department of Labor’s Office of Workers’ Compensation Programs, who are called compensationers. Annuitants are sometimes called retirees.
BENEFEDS
The enrollment and premium administration system for FEDVIP.
Benefits
Covered services or payment for covered services to which enrollees and covered family members are entitled to the extent provided by this brochure.
Calendar Year
From January 1, 2023 through December 31, 2023. Also referred to as the plan year.
Class A Services
Basic services, which include oral examinations, prophylaxis, diagnostic evaluations, sealants, and X-rays.
Class B Services
Intermediate services, which include restorative procedures such as fillings, prefabricated stainless steel crowns, periodontal scaling, tooth extractions, and denture adjustments.
Class C Services
Major services, which include endodontic services such as root canals, periodontal services such as gingivectomy, major restorative services such as crowns, oral surgery, bridges, and prosthodontic services such as complete dentures.
Class D Services
Orthodontic services.
Coinsurance
Coinsurance is the stated percentage of covered expenses you must pay.
Copay/Copayment
A copayment is a fixed amount of money you pay the provider when you receive the service.
Cosmetic Procedure
A cosmetic procedure is any procedure or portion of a procedure performed primarily to improve physical appearance or is performed for psychological purposes.
Covered Services
Covered services shall include only those services specifically listed in Section 5 Dental Services and Supplies. A covered service must be incurred and completed while the person receiving the service is a covered person. Covered services are subject to plan provisions for exclusions and limitations and meet acceptable standards of dental practice as determined by us.
Date of Service
The calendar date on which you visit the dentist's office and services are rendered.
Enrollee
The Federal employee, annuitant, or TRICARE-eligible individual enrolled in this plan.
FEDVIP
Federal Employees Dental and Vision Insurance Program.
Generally Accepted Dental Protocols
Dental Necessity means that a dental service or treatment is performed in accordance with generally accepted dental standards, as determined from multiple sources including but not limited to relevant clinical dental research from various research organizations including dental schools, current recognized dental school standard of care curriculums and organized dental groups including the American Dental Association, which is necessary to treat decay, disease or injury of teeth, or essential for the care of teeth and supporting tissues of the teeth.
In-Progress Treatment
Dental services that initiated in 2022 that will be completed in 2023.
Incur/Incurred
A covered service is deemed incurred on the date care, treatment or service is received.
Maximum Allowed Amount
The amount we use to determine our payment for services. If services are provided by an in-network dentist the maximum allowable amount is based on the discounted fee they accept as payment in full for the procedure or procedures. If services are provided by an out-of- network dentist the maximum allowed amount is based on BCBS FEP Dental’s determination of charges for the procedure or procedures.
Network Allowance
Network Allowance means the allowance per procedure that BCBS FEP Dental has negotiated with the provider and they have agreed to accept as payment in full for their services.
Plan
BCBS FEP Dental
Sponsor
Generally, a sponsor means the individual who is eligible for medical or dental benefits under 10 U.S.C. chapter 55 based on their direct affiliation with the uniformed services (including military members of the National Guard and Reserves).
TEI certifying family member
Under circumstances where a sponsor is not an enrollee, a TEI family member may accept responsibility to self-certify as an enrollee and enroll TEI family members
TRICARE-eligible individual (TEI) family member
TEI family members include a sponsor’s spouse, unremarried widow, unremarried widower, unmarried child, and certain unmarried persons placed in a sponsor’s legal custody by a court. Children include legally adopted children, stepchildren, and pre- adoptive children. Children and dependent unmarried persons must be under age 21 if they are not a student, under age 23 if they are a full-time student, or incapable of self-support because of a mental or physical incapacity.
Waiting Period
The amount of time that you must be enrolled in this plan before you can receive Orthodontic services. Note, there are no waiting periods associated with BCBS FEP Dental.
We/Us
BCBS FEP Dental
You
Enrollee or eligible family member.
If we determine a service less costly than the one performed by your dentist could have been performed by your dentist, we will pay benefits based upon the less costly services. See Section 3, How You Get Care.
Annual Benefit Maximum
The maximum annual benefit that you can receive per person.
Annuitants
Federal retirees (who retired on an immediate annuity) and survivors (of those who retired on an immediate annuity or died in service) receiving an annuity. This also includes those receiving compensation from the Department of Labor’s Office of Workers’ Compensation Programs, who are called compensationers. Annuitants are sometimes called retirees.
BENEFEDS
The enrollment and premium administration system for FEDVIP.
Benefits
Covered services or payment for covered services to which enrollees and covered family members are entitled to the extent provided by this brochure.
Calendar Year
From January 1, 2023 through December 31, 2023. Also referred to as the plan year.
Class A Services
Basic services, which include oral examinations, prophylaxis, diagnostic evaluations, sealants, and X-rays.
Class B Services
Intermediate services, which include restorative procedures such as fillings, prefabricated stainless steel crowns, periodontal scaling, tooth extractions, and denture adjustments.
Class C Services
Major services, which include endodontic services such as root canals, periodontal services such as gingivectomy, major restorative services such as crowns, oral surgery, bridges, and prosthodontic services such as complete dentures.
Class D Services
Orthodontic services.
Coinsurance
Coinsurance is the stated percentage of covered expenses you must pay.
Copay/Copayment
A copayment is a fixed amount of money you pay the provider when you receive the service.
Cosmetic Procedure
A cosmetic procedure is any procedure or portion of a procedure performed primarily to improve physical appearance or is performed for psychological purposes.
Covered Services
Covered services shall include only those services specifically listed in Section 5 Dental Services and Supplies. A covered service must be incurred and completed while the person receiving the service is a covered person. Covered services are subject to plan provisions for exclusions and limitations and meet acceptable standards of dental practice as determined by us.
Date of Service
The calendar date on which you visit the dentist's office and services are rendered.
Enrollee
The Federal employee, annuitant, or TRICARE-eligible individual enrolled in this plan.
FEDVIP
Federal Employees Dental and Vision Insurance Program.
Generally Accepted Dental Protocols
Dental Necessity means that a dental service or treatment is performed in accordance with generally accepted dental standards, as determined from multiple sources including but not limited to relevant clinical dental research from various research organizations including dental schools, current recognized dental school standard of care curriculums and organized dental groups including the American Dental Association, which is necessary to treat decay, disease or injury of teeth, or essential for the care of teeth and supporting tissues of the teeth.
In-Progress Treatment
Dental services that initiated in 2022 that will be completed in 2023.
Incur/Incurred
A covered service is deemed incurred on the date care, treatment or service is received.
Maximum Allowed Amount
The amount we use to determine our payment for services. If services are provided by an in-network dentist the maximum allowable amount is based on the discounted fee they accept as payment in full for the procedure or procedures. If services are provided by an out-of- network dentist the maximum allowed amount is based on BCBS FEP Dental’s determination of charges for the procedure or procedures.
Network Allowance
Network Allowance means the allowance per procedure that BCBS FEP Dental has negotiated with the provider and they have agreed to accept as payment in full for their services.
Plan
BCBS FEP Dental
Sponsor
Generally, a sponsor means the individual who is eligible for medical or dental benefits under 10 U.S.C. chapter 55 based on their direct affiliation with the uniformed services (including military members of the National Guard and Reserves).
TEI certifying family member
Under circumstances where a sponsor is not an enrollee, a TEI family member may accept responsibility to self-certify as an enrollee and enroll TEI family members
TRICARE-eligible individual (TEI) family member
TEI family members include a sponsor’s spouse, unremarried widow, unremarried widower, unmarried child, and certain unmarried persons placed in a sponsor’s legal custody by a court. Children include legally adopted children, stepchildren, and pre- adoptive children. Children and dependent unmarried persons must be under age 21 if they are not a student, under age 23 if they are a full-time student, or incapable of self-support because of a mental or physical incapacity.
Waiting Period
The amount of time that you must be enrolled in this plan before you can receive Orthodontic services. Note, there are no waiting periods associated with BCBS FEP Dental.
We/Us
BCBS FEP Dental
You
Enrollee or eligible family member.