Adjudication
The payer's decision process on a submitted claim.
What the insurer does between receiving a claim and issuing payment or denial: checking eligibility, applying plan rules, frequencies and downgrades, and calculating what it will pay. A claim that was rejected by the clearinghouse never reached adjudication at all — which is why rejections produce no EOB.
Aging
How long outstanding balances have been unpaid, grouped into buckets.
Usually reported in 30/60/90/120+ day buckets. The over-90 bucket is the one worth watching, and its direction matters more than its size — a large balance shrinking every week is healthier than a moderate one that has not moved in three months.
See also: Accounts receivable (A/R)
Alternate benefit provision
A plan clause paying for a cheaper treatment than the one performed.
The plan pays toward the least expensive treatment it considers adequate, and the patient covers the difference. Posterior composite downgraded to amalgam is the classic example. The claim is not denied — it simply pays less than was presented, which is worse for the patient relationship because someone already quoted them a number.
See also: Downgrade · LEAT
Annual maximum
The most a plan will pay in one benefit year.
Once reached, the patient is responsible for everything further that year. Tracking the remaining maximum is what makes end-of-year treatment conversations land — and what prevents presenting a large plan to someone who has £0 of benefit left.
Assignment of benefits
The patient directing the insurer to pay the practice instead of them.
Without it, some payers send payment to the patient and the practice has to collect from them afterwards — which is materially harder. Whether a payer honours assignment varies, particularly out-of-network.
Attachment
Supporting documentation sent with a claim.
Radiographs, perio charting, intraoral photos or a narrative establishing necessity. Attaching at submission costs a minute; adding after a denial costs that minute plus a rework cycle plus weeks of float. A large share of avoidable denials trace back to documentation that was never attached.
BAA (Business Associate Agreement)
The contract required before a vendor handles patient data.
Legally required under HIPAA before any protected health information is shared with a vendor working on your behalf. It defines permitted uses, safeguard obligations, breach notification duties and what happens to data at termination. A vendor that hesitates to sign one has answered your question.
CDT code
The standard procedure code set for dentistry.
Current Dental Terminology, maintained by the American Dental Association and updated annually. Codes are what you bill; using a retired code is a fast route to a rejection, which is why the annual update matters operationally rather than administratively.
Clearinghouse
The intermediary that validates and routes claims to payers.
Checks claims for format and completeness before forwarding them. If a claim fails here it is rejected rather than denied — it never reaches the payer, produces no EOB and no payment, and simply disappears until it surfaces on an aging report months later. Checking the rejection queue daily prevents more ninety-day surprises than any other single habit.
See also: Rejection
COB (Coordination of benefits)
The rules deciding which plan pays first when a patient has two.
The primary plan adjudicates first; the secondary considers what remains. COB loops are a common cause of aged A/R, because the secondary waits on the primary and nobody breaks the cycle. Where the payer's record of which plan is primary disagrees with yours, it will sit indefinitely until someone calls.
Coinsurance
The percentage share the patient pays after the deductible.
Distinct from a copay, which is a fixed amount. Coinsurance percentages typically differ by category — preventive, basic and major are rarely the same, and the headline percentage a patient quotes you is often the preventive one.
Covered entity
Under HIPAA, the practice itself.
Your practice is the covered entity; a vendor handling PHI on your behalf is a business associate. The distinction matters because the covered entity retains responsibility for choosing business associates that can actually meet their obligations.
Deductible
What the patient pays before the plan contributes.
Resets each benefit year. Many plans waive it on preventive care, which is a common source of confusion at checkout when a patient expects it to apply to everything.
Denial
The payer adjudicated the claim and declined to pay.
Different from a rejection, and the difference decides what you do next. A denial comes with a reason code and an EOB; it needs diagnosis, documentation and an appeal. Most denials are recoverable if someone actually works them — and the ones that repeat monthly are a submission problem, not a follow-up problem.
See also: Rejection
Downgrade
The plan paying at the rate of a less expensive material or procedure.
Most commonly posterior composite paid at the amalgam rate. Knowable at verification and expensive to discover afterwards, because by then the patient has been quoted a number that no longer holds.
See also: Alternate benefit provision
EFT (Electronic funds transfer)
Payment sent electronically rather than by cheque.
Faster and easier to reconcile, particularly when paired with an ERA. Worth enrolling with your higher-volume payers specifically — the reconciliation saving compounds.
Eligibility
Whether the patient has active coverage.
The easiest question in verification and the least useful answer. Confirming active coverage tells you almost nothing about whether the treatment you are about to present will be paid for — that depends on frequencies, history, downgrades and clauses, which an automated eligibility check is least likely to return accurately.
EOB (Explanation of benefits)
The payer's statement of how it processed a claim.
Shows billed amount, allowed amount, what the plan paid, and patient responsibility, with reason codes for anything reduced or denied. If there is no EOB, the claim was probably rejected rather than denied — it never reached adjudication.
ERA (Electronic remittance advice)
The electronic version of an EOB.
Machine-readable, so payments can be posted automatically rather than keyed. The operational win is not speed of posting but accuracy — auto-posting removes a category of human error from the ledger.
Fee schedule
The agreed amounts a payer allows per procedure.
In-network practices agree to accept the contracted amount as payment in full. Fee schedules loaded incorrectly produce estimates that are wrong in a consistent direction, which is the kind of error that goes unnoticed for months.
Frequency limitation
How often a plan will pay for a given procedure.
Two exams a year, bitewings once a year, FMX every three to five years, perio maintenance at set intervals. Along with payer-side history, this is the field that most often turns an accepted treatment plan into an unexpected patient balance — and patients rarely know when they last had something done elsewhere.
In-network / out-of-network
Whether the practice has a contract with that specific plan.
Worth checking per plan rather than per payer — a practice can be in-network with one product from an insurer and out with another. Assuming payer-level status is a recurring source of wrong estimates.
LEAT (Least expensive alternative treatment)
A clause paying only toward the cheapest adequate option.
Functionally the same mechanism as an alternate benefit provision, and appears under different names depending on the payer. Whatever it is called, the effect on patient responsibility is identical.
See also: Alternate benefit provision · Downgrade
Missing tooth clause
A plan excluding replacement of teeth lost before coverage began.
Catches practices out on bridges, partials and implants. Knowable at verification, expensive afterwards — and it is one of the fields an automated check will not return.
NPI (National Provider Identifier)
The unique identifier for a provider or organisation.
Required on claims. A wrong or mismatched NPI is a classic rejection cause — it fails at the clearinghouse rather than the payer, so it produces no EOB to alert anyone.
PHI (Protected health information)
Individually identifiable health information, protected under HIPAA.
Broader than most people assume — it includes appointment times, addresses and account numbers, not only clinical detail. Any vendor touching it needs a signed BAA and documented safeguards.
Posting
Recording payments and adjustments against the ledger.
Posting late means the ledger does not reflect reality, which quietly corrupts every report built on it — including the aging you are using to decide what to work.
Predetermination
Asking the payer in advance what it will cover.
Also called pre-authorisation or pre-estimate depending on payer. Useful for large treatment plans, and worth remembering it is an estimate rather than a guarantee of payment — coverage can still change before the claim is adjudicated.
Recall (continuing care)
Scheduled return visits, usually hygiene.
Recall drives both restorative diagnosis and retention, so a lapsing recall list is an early indicator of a revenue problem several months out. It is also the cheapest production in the practice and the first thing to get dropped when the front desk is busy.
Rejection
The clearinghouse stopped the claim before the payer saw it.
A format, identifier or missing-field problem. Produces no EOB and no payment — the claim simply vanishes from view until an aging report surfaces it. This makes an unnoticed rejection arguably worse than a denial, and it is why the rejection queue needs checking daily rather than weekly.
See also: Denial · Clearinghouse
Timely filing
The deadline for submitting or appealing a claim.
Varies by payer and contract, commonly 90 days to a year from date of service. It is a hard wall: past it, an appeal generally requires documented proof of timely original submission — which is exactly what a practice with a stalled backlog usually cannot produce. This is why aged A/R gets worked oldest-and-largest first.
UCR (Usual, customary and reasonable)
A payer's view of a typical fee in your area.
Used by some out-of-network plans to cap what they will pay. The methodology is rarely transparent, so estimates against UCR carry more uncertainty than estimates against a contracted fee schedule — and patients should be told that rather than given false precision.
Unscheduled treatment
Treatment diagnosed and accepted but never booked.
For most practices this is the largest pool of production they already own and are not collecting. It is also the warmest outbound call list in the building, because these patients have already agreed they need the work.
Waiting period
Time a member must be enrolled before a category is covered.
Common on major work. Knowable at verification, and a frequent cause of large unexpected patient balances when it is not checked before a plan is presented.
Write-off (adjustment)
Removing a balance you will not collect.
Contractual write-offs are the difference between your fee and the contracted amount — normal and expected. Discretionary write-offs of genuinely uncollectable aged balances are also healthy, because carrying them makes the practice look like it has assets it does not.