This glossary defines how terms are used throughout the site. Other pages link here instead of repeating the same definitions.
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835, The X12 electronic remittance advice: what the payer paid, what it adjusted, and why, in coded form. See Understanding 835s.
837D, The X12 electronic dental claim (005010X224A2). Carries CDT codes, tooth numbers, surfaces, and oral cavity designations; maps to the paper ADA Dental Claim Form. See Understanding the 837D.
Accounts receivable (AR), Amounts owed to a practice for services delivered but not yet collected, from payers and patients.
ADA Dental Claim Form, The paper dental claim, maintained by the ADA; the current version is the 2024 form. The paper equivalent of the 837D. See CDT & the 837D.
Adjudication, The payer’s process of evaluating a claim against eligibility, benefits, contract terms, coding rules, and coverage policy to determine payment.
AFR (Applicable Federal Rate), Interest rates published monthly by the IRS. Related-party loans below the AFR trigger imputed interest under IRC § 7872. See Intercompany loan note.
AKS (Anti-Kickback Statute), 42 U.S.C. § 1320a-7b(b). Criminal, intent-based prohibition on remuneration to induce or reward referrals of federally reimbursable items or services. See Stark and anti-kickback.
Allowed amount, The amount recognized under the payer’s contract for a service, rather than the practice’s billed charge.
Alternate benefit provision, See Downgrade.
Annual maximum, The cap on what a dental plan pays per patient per plan year, typically 1,000–2,000. Once the maximum is exhausted, the plan may assign further covered charges to the patient under its benefit design. See Denials vs downgrades.
ASC 810, The US GAAP consolidation standard, including the variable interest entity model under which PCs are typically consolidated into a DSO’s audited financials. See How investors read DSO financials.
BAA (Business Associate Agreement), HIPAA-required contract between a covered entity and a business associate. Required content at 45 C.F.R. § 164.504(e).
Balance billing, Billing a patient the difference between the charge and the allowed amount. Prohibited for in-network care, and restricted out-of-network by the No Surprises Act.
Billed charge, The practice’s full-fee amount submitted on a claim. A contracted payer generally adjudicates against its allowed amount instead.
Biller, The person or team responsible for claim submission, rejection follow-up, payment posting, denials, and related accounts-receivable work. See What billers actually do.
Business associate, Under HIPAA, an entity that creates, receives, maintains, or transmits PHI on a covered entity’s behalf. A DSO generally acts as the PC’s business associate when it performs those functions for the practice.
CAQH ProView, A shared credentialing database most commercial payers pull from. Requires periodic re-attestation.
CARC (Claim Adjustment Reason Code), X12-maintained code explaining why a claim or line was paid differently than billed. Always paired with a group code. See CARC codes.
CDT (Current Dental Terminology), The Code on Dental Procedures and Nomenclature; dentistry’s procedure code set, maintained and copyrighted by the ADA and revised annually effective January 1. Codes are the letter D plus four digits, in twelve service categories. The HIPAA-designated code set for dental claims (45 C.F.R. § 162.1002). See CDT & the 837D.
Chargeback, A forced reversal of a card payment initiated by the cardholder through their issuing bank. See Chargebacks.
Clean claim, A claim accepted on first submission and adjudicated without denial.
Clearinghouse, An intermediary that translates, validates, routes, and returns claims and remittances between providers and payers. See What is a clearinghouse?.
CO (Contractual Obligation), Group code reporting that the provider absorbs the amount under the payer contract. The practice generally may not bill that amount to the patient.
COB (Coordination of benefits), Determining which payer pays first when a patient has multiple coverages. For dependent children on two dental plans, the birthday rule usually decides: the plan of the parent whose birthday falls earlier in the calendar year is primary.
Contractual adjustment, Billed charge minus allowed amount. A write-off, arriving as CO-45.
Covered entity, Under HIPAA, a health plan, clearinghouse, or provider transmitting health information electronically for covered transactions. The PC is a covered entity.
CPOD (Corporate Practice of Dentistry), The state-law doctrine restricting non-dentist ownership of dental practices, employment of dentists to practice, or control over clinical judgment. The restrictions, exceptions, and consequences vary by state. See The CPOD doctrine.
CPOM (Corporate Practice of Medicine), Medicine’s analogue to CPOD. Covered in depth by the sibling MSO-PC Wiki.
CPT, Medical procedure code set, licensed by the AMA. Appears in dentistry only in medical-crossover billing. See Bill medical plans for dental work.
Credible allegation of fraud, An allegation from any source, verified by the State and bearing indicia of reliability, that triggers a mandatory Medicaid payment suspension under 42 C.F.R. § 455.23. Requires no finding about who actually submitted the claims. See Provider identity theft.
Credentialing, Verification of a dentist’s qualifications and their linkage to a group’s payer contract. Distinct from contracting.
Credit balance, Money on an account that the practice is not entitled to keep and should record as a liability rather than revenue.
Days in AR, Total accounts receivable divided by average daily charges.
DBA (dental benefit administrator), A company administering dental benefits for a Medicaid program, an MCO, or another payer; DentaQuest, MCNA, Liberty, SKYGEN, Avesis, Envolve. Claims go to the administrator, not the state. (In banking paperwork, DBA means “doing business as”; context distinguishes them.) See Dental payer landscape.
De-identification, Removing identifiers under 45 C.F.R. § 164.514 by Safe Harbor or Expert Determination, after which data is no longer PHI and HIPAA does not apply. Free-text clinical narratives require particular care because identifying details can remain in the text. See LLMs, zero data retention, and HIPAA.
Delta Dental Premier / PPO, Delta Dental’s two national networks. Premier is the legacy network with broader participation and higher maximum allowable fees; PPO is the discounted network. A dentist can be Premier-only, both, or out of network, and each of Delta’s 39 member companies contracts separately for its own states. See Dental payer landscape.
Denial, A claim the payer adjudicated and refused to pay, in whole or part. Distinct from a rejection, and distinct from a downgrade. See Denials vs downgrades.
Designated health services (DHS), The service categories to which the Stark Law’s referral prohibition applies, including clinical lab, physical therapy, imaging, and DME.
Dormancy period, The time unclaimed property must remain unclaimed before it must be reported to the state.
Downgrade, A plan pricing a service using the allowance for a less expensive covered alternative under an alternate-benefit or LEAT (least expensive alternative treatment) clause. A common example is a posterior composite priced at the amalgam allowance. The remittance, plan, participation agreement, and notice rules determine how the difference is allocated and whether an appeal is appropriate. See Denials vs downgrades.
DSO (Dental Support Organization), A company that provides administrative or other support services to one or more dental practices. The DSO and practice may be connected through a management services agreement, but the permitted ownership, services, and control allocation depend on state law and the actual structure. “Dental service organization” is a common variant. See What is a DSO?.
DSO registration, Informal shorthand for several different dental-business regimes, including support-company registration, business-manager registration, dental business-entity registration, and non-dentist-owner licensure. The filing depends on the regulated role and trigger rather than the acronym. See Register a DSO.
EDI (Electronic Data Interchange), Structured electronic exchange of business documents. In healthcare, the X12 standards mandated by HIPAA.
EFT (Electronic Funds Transfer), Direct deposit of payer payments. The health care standard is ACH CCD+ with an addenda record carrying the TRN.
Eliminations, Removing intercompany transactions on consolidation so the same dollars aren’t counted twice.
ERA (Electronic Remittance Advice), The 835 transaction. ERA enrollment is separate from EFT enrollment.
ERISA, 29 U.S.C. § 1001 et seq. Governs employer benefit plans and broadly preempts state insurance law as applied to self-funded plans.
Escheatment, The process by which unclaimed property becomes the state’s. See Escheatment by state.
Extrapolation, Applying an audit sample’s error rate across a larger universe of claims to calculate an overpayment demand.
FCA (False Claims Act), 31 U.S.C. §§ 3729–3733. Prohibits knowingly submitting false claims to the government and permits treble damages and per-claim penalties. Private relators may bring claims through the qui tam provisions.
Fee-splitting, State-law prohibition on sharing professional fees with non-licensees. Distinct from CPOD. See Fee-splitting.
FMV (Fair market value), What an unrelated party would pay for the same services. Management fees and compensation are often evaluated against this standard.
Frequency limitation, A plan rule paying for a service only at stated intervals, such as two prophylaxes per year, annual bitewings, or a crown on the same tooth after a specified number of years. When the payer applies the rule correctly, the result is a benefit limitation rather than a claim defect.
Friendly PC, A professional entity owned by a licensed dentist aligned with and contractually connected to a DSO, with succession pre-arranged. Industry jargon, not a legal term. See The friendly PC.
Fully-insured, A plan where the insurance company bears the risk. Contrast self-funded.
Good faith estimate (GFE), Required estimate of expected charges for uninsured and self-pay patients under the No Surprises Act.
Group code, CO, PR, OA, or PI. Determines who bears an adjustment. See Group codes.
Group NPI, See Type 2 NPI.
HCPCS Level II, CMS-maintained codes for supplies, drugs, and services not in CPT. In dentistry, seen in medical-crossover billing; sleep apnea appliances bill as HCPCS DME.
HIPAA, Governs health information privacy and security and mandates standard electronic transactions.
Hygiene reappointment rate, The share of hygiene patients who book their next recall visit before leaving the office. Because hygiene may account for 25–35% of production, operators and acquirers use this rate when evaluating schedule continuity and future production.
ICD-10-CM, Diagnosis code set. In dentistry, used mainly on medical-crossover claims; the 837D can carry diagnosis codes where a payer requires them.
Incident-to, Medicare billing of services furnished by auxiliary personnel under a supervising practitioner’s NPI, subject to specific supervision requirements. It is a medical-side concept relevant only to crossover billing and does not provide a workaround for uncredentialed providers.
Intercompany, Transactions between the PC and the DSO. Must be characterized as a fee or a loan, and documented as such.
LEAT (Least Expensive Alternative Treatment), See Downgrade.
LLM (Large Language Model), An AI model that processes and generates text. When a provider handles PHI on a covered entity’s behalf, the provider is a business associate and a BAA is required. See LLMs, zero data retention, and HIPAA.
LCD / NCD, Local and National Coverage Determinations. Define Medicare medical necessity, LCDs regionally by MAC. Relevant to dental only in crossover billing.
LEIE, The OIG List of Excluded Individuals/Entities. Screen monthly.
Lockbox, A bank-operated mailing address where payer and patient checks are received and deposited.
MAC (Medicare Administrative Contractor), Regional contractor processing Medicare Part A/B claims. Touches dental groups only through crossover and DMEPOS billing.
Management fee, The compensation a practice pays a support company for services under an MSA. Its formula, services, control implications, tax treatment, and enforceability are state- and fact-specific. See Where the profit lives.
Membership plan, A practice-run subscription charging a flat monthly or annual fee for preventive care and a discount schedule for other work. It is not insurance and should not be marketed as insurance; several states regulate these arrangements as discount plans. See Membership and discount plans.
Missing tooth clause, A plan exclusion refusing to pay for replacement (bridge, denture, implant) of a tooth extracted before the patient’s coverage began. Enforced by requesting prior radiographs.
MSA (Management Services Agreement), The contract between DSO and PC defining services, fee, and the clinical carve-out. See MSA clause anatomy.
MSO (Management Services Organization), The general healthcare term for the type of support organization dentistry often calls a DSO. See DSO; for the model outside dentistry, see the sibling MSO-PC Wiki.
NEA number, The reference number an attachment service (NEA FastAttach, now Vyne Dental) returns when radiographs, perio charts, or narratives are uploaded to its repository. The number is placed on the claim so the payer can retrieve the documentation. The X12 275 attachment standard has a May 2028 compliance date and will change this workflow. See Dental attachments.
Net collection rate, Payments received divided by charges after contractual adjustments. It measures collections against the amount the practice was entitled to collect.
NCCI, CMS’s National Correct Coding Initiative edits, identifying code pairs that should not be reported together. Applies to crossover and Medicaid billing.
Network leasing, A PPO network renting its contracted dentists, and their discounted fees, to other payers, TPAs, and umbrella networks. The first sign is often an EOB from a payer you never contracted with. Many states now require notice or consent. See Network leasing.
No Surprises Act, Restricts balance billing in specified out-of-network situations and requires good faith estimates for self-pay patients.
NPI (National Provider Identifier), 10-digit identifier. Type 1 for individuals, Type 2 for organizations.
NPPES, The CMS system that issues and maintains NPIs.
OA (Other Adjustment), Group code for adjustments that are neither contractual nor patient responsibility.
Overpayment, Money received that you are not entitled to keep. For Medicare and Medicaid, subject to the 60-day report-and-return rule.
PA (Professional Association), A professional entity form used in Texas, Florida, and some other states.
Par / non-par, Participating / non-participating in a payer’s network.
Payment suspension, A program’s withholding of all or part of a provider’s payments during a fraud investigation. Discretionary under Medicare (42 C.F.R. § 405.371), mandatory under Medicaid absent good cause (42 C.F.R. § 455.23).
Payer, An entity that pays healthcare claims. The term includes more than insurance companies. See Payers vs insurance companies.
PC (Professional Corporation), A corporation whose ownership is restricted to licensees of a specified profession.
PECOS, The Medicare provider enrollment system.
PHI (Protected Health Information), Individually identifiable health information under HIPAA. Transactions such as 835s, 837s, and 271s generally contain PHI.
PI (Payer Initiated Reduction), Group code for a payer’s own reduction, not contractual. Often appealable.
PLB (Provider Level Adjustment), The 835 segment carrying adjustments outside claim detail, including takebacks, interest, and withholds. Reconciliation must account for PLB amounts separately from claim payments.
PLLC, Professional limited liability company.
PMS (Practice management system), Dentistry’s core software: scheduling, clinical charting, treatment plans, imaging integrations, and billing in one system; the dental equivalent of medicine’s EHR-plus-PM stack. See Choose a PMS.
POS (Place of Service), A code identifying where a service was delivered. It can affect payment.
PR (Patient Responsibility), Group code reporting an amount as patient responsibility. Confirm the remittance, plan, contract, prior payments, and any required notice before billing.
Preauthorization, A payer’s advance approval required before specified services are payable. Requirements vary by plan and are common in some Medicaid and DHMO products. Distinct from a voluntary predetermination.
Predetermination, A voluntary pre-treatment request asking the payer to estimate benefits for planned care. It is not a payment guarantee because final adjudication applies the coverage, eligibility, remaining annual maximum, and frequency rules in effect for the claim. See Get predeterminations.
Professional entity, Umbrella term for PC, PLLC, and PA.
Proprietor clause, A dental-practice-act provision that includes specified ownership, maintenance, operation, management, or proprietorship conduct in the practice of dentistry. The verbs, exceptions, persons covered, and remedies vary by state; Texas and Florida attach criminal consequences to specified unlicensed conduct. See DSO laws by state.
Provider identity theft, Use of a dentist’s or entity’s NPI, license, and TIN to submit claims they never rendered, ordered, or authorized. The fraudster may receive the payment while the provider of record receives an overpayment demand. See Provider identity theft.
PTAN, Provider Transaction Access Number. A MAC-assigned identifier distinct from the NPI.
Qui tam, The False Claims Act provision letting a private relator sue on the government’s behalf and share in the recovery.
QoE (Quality of Earnings), A diligence review normalizing reported EBITDA.
RARC (Remittance Advice Remark Code), Code qualifying a CARC with additional detail. See RARC codes.
RBRVS, The resource-based relative value scale underlying the Medicare Physician Fee Schedule. Touches dental only in crossover billing.
RCM (Revenue Cycle Management), The end-to-end process of converting care into cash; also the category of vendors who do it for you.
Recoupment, A payer recovering a prior payment, by demand or by offset. See Handle recoupments.
Rejection, A claim refused before adjudication, signalled by a 999 or 277CA. Because no adjudication occurred, the practice generally corrects and resubmits the claim rather than appealing a denial.
Retro-effective date, A payer effective date backdated to the application or practice start date.
Self-funded, A plan where the employer bears the claims risk and a carrier acts only as administrator. ERISA generally governs these plans and broadly preempts state insurance law as applied to them, including many state network-leasing and non-covered-services protections.
Silent PPO, A discount taken by a payer with no direct contract with you, accessed through a rental network. See Network leasing.
Stark Law, 42 U.S.C. § 1395nn. Civil, strict-liability prohibition on physician referrals for designated health services to entities with which they have a financial relationship. Its application in dentistry is limited but should still be assessed where designated health services are involved. See Stark and anti-kickback.
Stock transfer restriction agreement, Sets the treatment of the PC’s equity when defined transfer events occur. See Draft the stock transfer restriction.
Subpart, An additional organizational NPI for a distinct component of one entity.
Taxonomy code, A 10-character code identifying provider type and specialty. The code submitted on a claim should match the payer’s enrollment record. See Taxonomy codes.
Timely filing, The deadline by which a claim must reach the payer. Missing it produces CARC 29.
TPA (Third-Party Administrator), An entity administering claims for a self-funded plan without bearing risk.
TRN, The 835 segment carrying the reassociation trace number, used to match a remittance to its deposit. The TRN is a more reliable match key than the payment amount.
Type 1 NPI, An individual dentist’s NPI. Follows the person for life.
Type 2 NPI, An organization’s NPI. Tied to the entity’s EIN.
Unbundling, Billing separately for components that should be billed under a single comprehensive code.
Underpayment, A claim paid for less than the contract requires. Finding one usually requires comparing the remittance with the contracted fee schedule. See Underpayments and contracts.
Upcoding, Billing a higher-level code than the documented service supports.
VCC (Virtual Credit Card), A single-use card number a payer sends instead of an EFT. Processing fees commonly reduce the amount the practice receives.
VIE (Variable Interest Entity), An entity consolidated under ASC 810 based on power and economics rather than equity ownership. PCs are typically VIEs of their DSO.
Write-off, Revenue recorded as uncollectible. Contractual write-offs (CO) are expected; denial and timely-filing write-offs are losses.
X12, The standards body whose transaction formats HIPAA adopted for healthcare EDI. See X12 transaction sets.
Zero data retention (ZDR), A configuration in which an AI provider does not persist prompts and outputs after serving the request. ZDR is a storage control, not proof of HIPAA compliance or a substitute for a BAA. Retention settings and BAA coverage must be evaluated separately. See LLMs, zero data retention, and HIPAA. Last modified on August 21, 2026