Glossary
A localized inflammation due to a collection of pus in the bone or soft tissue, usually caused by an infection.
A tooth or implant used to support a prosthesis. A crown unit used as part of a fixed bridge.
Certification that an organization meets the reviewing organization's standards. Examples: accreditation of HMOs by the National Committee on Quality Assurance (NCQA) or accreditation of hospitals by the Joint Commission of Accreditation of Healthcare Organizations (JCAHO).
The administrative procedure used to process a claim for service according to the covered benefit.
An employee must work for the employer on a regular basis in the usual course of the employer's business to be considered an active, full-time employee and eligible for coverage. Usually, a minimum number of hours of regular work is specified.
Administrative Service Only (ASO)
An arrangement in which a licensed insurer provides administrative services to an employer's health benefits plan (such as processing claims), but doesn't insure the risk of paying benefits to enrollees. In an ASO arrangement, the employer pays for the health benefits. Non-HMO CIGNA HealthCare benefits plans may be administered by Connecticut General Life Insurance Company on an ASO basis.
The maximum fee that a health plan will reimburse a provider for a given service.
A facility offering a "non-traditional" ("not like a hospital") setting for giving birth. While alternative birthing centers can range from free-standing centers to special areas within hospitals, birthing centers are generally known for a more comfortable, home-like atmosphere, allow more participation by the father and have more procedural flexibility than commonly found in hospital births.
A dental filling material, composed of mercury and other minerals, used to fill decayed teeth.
A surgical procedure used to recontour the supporting bone structures in preparation of a complete or partial denture.
A general term for care that doesn't involve admission to an inpatient hospital bed. Visits to a doctor's office are a type of ambulatory care. Ambulatory SurgerySurgical procedures performed that do not require an overnight hospital stay. Procedures can be performed in a hospital or a licensed surgical center. Also called Outpatient Surgery.
American Dental Association (ADA)
A professional association of dentists dedicated to serving the public and profession of dentistry.
American Medical Association (AMA)
A professional association of physicians dedicated to promoting the art and science of medicine and the betterment of public health.
Ancillary care :Diagnostic and/or supportive services such as radiology, physical therapy, pharmacy or laboratory work.
Ancillary care :Diagnostic and/or supportive services such as radiology, physical therapy, pharmacy or laboratory work.
A class of drugs that eliminates or reduces pain. See local anesthetic.
The day after a coverage period ends under a health benefits plan. Usually, the month and day that a health benefits plan first goes into effect becomes its anniversary date each year.
The most a plan member will pay per year for covered health expenses before the plan pays 100% of covered health expenses for the rest of that year.
Refers to the teeth and tissues located towards the front of the mouth (upper or lower incisors and canines).
The tip or end of the root of the tooth.
The amputation of the apex of a tooth.
A process available to the patient, their family member, treating provider or authorized representative to request reconsideration of a previous adverse determination.
When a covered person authorizes his or her health benefits plan to directly pay a health care provider for covered services. Traditional health insurance pays benefits directly to the covered person.
See Precertification.
Assessment and therapeutic services used in the treatment of mental health and substance abuse problems.
A person who is eligible to receive benefits under a health benefits plan. Sometimes "beneficiary" is used for eligible dependents enrolled under a benefits plan; "beneficiary" can also be used to mean any person eligible for benefits, including both employees and eligible dependents.
The benefit is usually determined as a percentage of the employee's pre-disability income up to an overall maximum benefit amount.
The coverage period, usually 12 months long, which is used for administration of a health benefits plan.
The portion of the costs of covered services paid by a health plan. For example, if a plan pays the remainder of a doctor's bill after an office visit copayment has been made, the amount the plan pays is the "benefit." Or, if the plan pays 80% of the reasonable and customary cost of covered services, that 80% payment is the "benefit."
A term informally used to refer to the employer's benefits plan or to the benefits plan options from which the employee can choose. "Benefits package" highlights the fact a health benefits plan is a compilation of specific benefits.
A two-cusped tooth found between the molar and the cuspid also known as an eye tooth or canine tooth.
A process of removing tissue to determine the existence of pathology.
X-rays taken of the crowns of teeth to check for decay.
The technique of applying a chemical agent, usually hydrogen peroxide, to the teeth to whiten them.
Any physician who has completed medical school, internship and residency in his or her chosen specialty and has successfully completed an examination conducted by a group (or board) of peers.
A process to chemically etch the tooth's enamel to better attach (bond) composite filling material, veneers, or plastic/acrylic.
The breakdown and loss of the bone that supports the teeth, usually caused by infection or long-term occlusal (chewing areas of the teeth) stress.
A drug manufactured by a pharmaceutical company which has chosen to patent the drug's formula and register its brand name.
A nonremovable restoration that is used to replace missing teeth.
Brush biopsy is a painless procedure used to gather cells in the mouth. The dentist uses a small brush to take a tissue specimen, which is then sent to a laboratory for analysis to determine the presence of pre-cancerous or early stage cancerous cells. Laboratory results are used to determine the need for further procedures.
The involuntary clenching or grinding of the teeth.
The hard deposit of mineralized plaque that forms on the crown and/or root of the tooth. Also referred to as tartar.
The second tooth from the big front tooth, commonly called the eye tooth or cuspid.
Another term for crown; usually referring to a crown for a front tooth.
The correct technical term for decay which is the progressive breaking down or dissolving of tooth structure, caused by the acid produced when bacteria digest sugars.
A term historically used for licensed insurance companies, although now is sometimes used to include both licensed insurers and HMOs.
Coordination of services to help meet a patient's health care needs, usually when the patient has a condition which requires multiple services from multiple providers. This term is also used to refer to coordination of care during and after a hospital stay.
A layman's term for tooth decay. Also, the dental term for the hole that is left after decay has been removed.
A special type of glue used to hold a crown in place. It also acts as an insulator to protect the tooth's nerve.
The very thin, bonelike structure that covers the root of the tooth.
See Precertification.
The amount billed by a provider for services rendered to a participant.
Treatment of malignant disease by chemical or biological antinoeplastic agents.
The name derived from Connecticut General Insurance and Insurance Company of North America when they merged in 1982.
A claim is a request for payment under the terms of a health benefits plan.
Claims are Paid, Pended, Denied, or Received-Not-Yet-Processed.
The forceful holding together of the upper and lower teeth, which places stress on the ligaments that hold the teeth to the jawbone and the lower jaw to the skull.
General procedures and suggestions about what constitutes an acceptable range of practices for particular diseases or conditions. These guidelines are usually developed by a consensus of doctors in a given field, such as radiology or cardiology.
Diagnostic services a doctor provides during delivery of medical services, consultations or care.
The portion of eligible expenses that plan members are responsible paying, most often after the deductible is met. It's usually determined as a percentage of the total cost.
The extensive dental restoration involving 6 or more units of crown and/or bridge in the same treatment plan. Using full crowns and/or fixed bridges which are cemented in place, the your dentist will rebuild natural teeth, fill in spaces where teeth are missing and establish conditions which allow each tooth to function in harmony with the occlusion (bite). The extensive procedures involved in complex rehabilitation require an extraordinary amount of time, effort, skill and laboratory collaboration for a successful outcome.
A tooth-colored filling made of plastic resin or porcelain.
A discussion with another health care professional when additional feedback is needed during diagnosis or treatment. Usually, a consultation is by referral from a primary care physician.
A legal agreement between an individual subscriber or an employer group and a health plan that describes the benefits and limitations of the coverage.
The option to purchase individual coverage by a person who will no longer have access to group health insurance.
A provision in a contract that applies when a person is covered under more than one group health benefits program. It requires that payment of benefits be coordinated by all programs to eliminate overinsurance or duplication of benefits.
Amount that a plan member must pay the provider at the time of service, usually after the deductible is met for eligible expenses.
Any dental treatment or repair that is solely rendered to improve the appearance of the teeth or mouth.
The benefits that are provided according to the terms of a participant's specific health benefits plan.
Coverage End Date displays the date that coverage ends for a participant. This field is blank, if the participant is considered covered as of the date of the inquiry.
Hospital, medical, and other health care services incurred by the enrollee that are entitled to a payment of benefits under a health benefit contract. The term defines the type and amount of expense that will be considered in the calculation of benefits.
A process that reviews a health care provider's credentials against the credentials required to participate in a managed care network. To participate in a CIGNA HealthCare network, physicians and facilities are thoroughly credentialed before being admitted and are recredentialed every two years. They must meet specific criteria for continued participation in a CIGNA HealthCare provider network.
The portion of a tooth that is covered by enamel. Also a dental restoration that covers the entire tooth and restores it to its original shape.
A surgical procedure exposing more tooth for restorative purposes.
A deep scaling of that portion of the tooth below the gum line. Purpose is to remove calculus and infected gum tissue.
See canine tooth.
The protruding portion(s) of a tooth's chewing surface.
Care that is provided primarily to meet the personal needs of a patient. The care is not meant to be curative or providing medical treatment.
The date the service was provided to the participant as specified on the claim.
An outpatient facility that is licensed to provide outpatient care and treatment, usually for mental or nervous disorders or substance abuse.
See caries.
See primary teeth.
The dollar amount that a plan member must pay for eligible health expenses before a traditional health plan kicks in with benefits.
One of the most important provisions in a disability contract is the definition of disability that will be used to determine an employee's eligibility for benefits.
Definition of Total Disability
One of the most important provisions in a disability contract is the definition of disability that will be used to determine an employee's eligibility for benefits.
Under this definition, an employee will be considered disabled only if s/he is unable to perform the duties of his or her occupation.
Under this definition, an employee will be considered disabled only if s/he is unable to work in any occupation for which s/he is qualified by education, training, or experience. This is closely related to the definition that the Social Security Administration uses in determining disability.
Definition of Partial/Residual Disability
This definition of disability applies when an employee is able to return to work part-time or even full-time but with a loss of earnings. If the employee is working in this limited capacity and is earning less than a certain level of income, s/he will still be eligible for limited benefits under the plan. Not all disability carriers use this terminology to describe a "part-time" work situation, but most provide some type of benefit to encourage return to work.
Claims that are not issued a bank draft/remittance due to a specific reason code.
A thin, nylon string, waxed or untaxed, that is inserted between the teeth to remove food and plaque.
A dental professional specializing in cleaning the teeth by removing plaque, calculus, and diseased gum tissue. He/She acts as the patient's guide in establishing a proper oral hygiene program.
The part of the tooth that is under both the enamel which covers the crown and the cemented which covers the root
A removable appliance used to replace teeth. A complete denture replaces all of the upper teeth and/or all the lower teeth. See also partial denture
A person eligible for coverage under an employee benefits plan because of that person's relationship to an employee. Spouses, children and adopted children are often eligible for dependent coverage
Tests and procedures ordered by a physician to help diagnose or monitor a patient's condition or disease. Diagnostic tools include radiology, ultrasound, nuclear medicine, laboratory and pathology services or tests
The procedure in which the exposed pulp is covered with a dressing or cement that protects the pulp and promotes healing and repair
Identifying a patient's health care needs after discharge from inpatient care
Voluntarily terminating one's participation in a health benefits plan
See Formulary
A localized inflammation of the tooth socket following an extraction due to infection or loss of a blood clot
When a person has coverage for the same health services under more than one health benefits plan
Equipment that can withstand repeated use and is primarily and usually used to serve a medical purpose, is generally not useful to a person in the absence of illness or injury, and is appropriate for use in the home.
The date on which coverage under a health benefits plan begins.
Provisions contained in each health benefits plan that specify who qualifies for coverage under that plan.
This is the period of time between the date the disability begins and the beginning of the benefit payment period. It is the period during which an employee must be disabled before payment of benefits begins. It is sometimes referred to as the Qualifying Period.
An accident or sudden illness that a person with an average knowledge of medical science believes needs to be treated right away or it could result in loss of life, serious medical complications or permanent disability. Emergencies are covered by your CIGNA HealthCare plan 24 hours a day, seven days a week, no matter where you are. Whenever there's a serious accident or sudden illness, and symptoms are severe and they occur unexpectedly, seek medical help immediately. Examples of emergency situations include: uncontrolled bleeding, seizure or loss of consciousness, shortness of breath, chest pain or squeezing sensations in the chest, suspected overdose of medication or poisoning, sudden paralysis or slurred speech, severe burns, broken bones or severe pain.
The hard, calcified (mineralized) portion of the tooth which covers the crown. Enamel is the hardest substance in the body.
The dental specialty that deals with injuries to or diseases of the pulp, or nerve, of the tooth.
An individual who is enrolled and eligible for coverage under a health plan contract. Also called Member.
Group disability coverage is generally sold as "guaranteed issue," which means that evidence of insurability is not required.
Specific conditions or services that are not covered under the benefit agreement.
Experimental, investigational or unproven procedures and treatments.
The date indicated in an insurance contract as the date coverage expires.
A statement provided by the health benefits administrator that explains the benefits provided, the allowable reimbursement amounts, any deductibles, coinsurance or other adjustments taken and the net amount paid. A participant typically receives an explanation of benefits with a claim reimbursement check or as confirmation that a claim has been paid directly to the provider.
A medical care institution for patients who require long-term custodial or medical care, especially for chronic disease or a condition requiring prolonged rehabilitation therapy.
When a person's coverage is extended under certain conditions, such as disability, after their group health coverage would otherwise have ended.
Surgical removal of bone or tissue.
There are specific provisions included in group disability plans that preclude coverage in certain situations. Typically, a plan will not pay benefits for disabilities caused by war or a self-inflicted injury.
The overgrowth of normal bone.
Some policies require that employees be totally disabled before payments begin. Other policies pay out for partial disability for a limited time, but most often only if the partial disability follows a period of total disability for the same cause.
The outside of the crown of the tooth.
The removal of a tooth.
The outside of the mouth.
Material used to fill a cavity or replace part of a tooth.
Flexible benefits plan: A type of benefits program that offers employees a menu of benefit options, allowing them to create a benefits package which best suits their individual needs.
Flexible benefits plan: A type of benefits program that offers employees a menu of benefit options, allowing them to create a benefits package which best suits their individual needs.
Flexible Spending Account (FSA)
An account that reimburses the participant for qualified health costs or dependent care expenses through one pre-tax savings account. Employees or employers or both fund the account. At the end of each year, unused dollars are forfeited by the account holder.
See dental floss.
A chemical compound used to prevent dental decay, utilized in fluoridated water systems and/or applied directly to the teeth.
A list of preferred, commonly prescribed prescription drugs. These drugs are chosen by a team of doctors and pharmacists because of their clinical superiority, safety, ease of use and cost.
Muscle fibers covered by a mucous membrane that attaches the cheek, lips and or tongue to associated dental mucosa.
The removal of a frenum.
A primary care physician who provides a broad range of routine medical services and refers patients to specialists, hospitals and other providers as necessary. This traditional primary care physician role is called a "gatekeeper" function. Under some benefits plans, a referral by the primary care physician is required to obtain services from other providers.
A prescription drug that has the same active-ingredient formula as a brand-name drug. A generic drug is known only by its formula name and its formula is available to any pharmaceutical company. Generic drugs are rated by the Food and Drug Administration (FDA) to be as safe and as effective as brand-name drugs and are typically less costly.
The soft tissue that covers the jawbone. Also referred to as the gums.
The removal of gingiva (gum).
An inflammation or infection of the gingiva (gum tissue); the initial stage of gum disease.
A surgical procedure to reshape or repair the gingiva (gum).
A piece of tissue or synthetic material placed in contact with tissue to repair a defect or supplement a deficiency.
See gingiva.
See periodontal disease.
Any health care service or program that helps maintain a person's good health. Health maintenance services include all standard preventive medical practices, such as immunizations and periodic examinations, as well as health education and special self-help programs.
A term that has different meanings depending upon the context. "Health plan" can be used to mean an HMO, a health benefits plan provided by an employer to its employees, or a health benefits plan offered to employers by an insurer or third party administrator.
Health services rendered in the home to an individual who is confined to the home. Such services are provided to individuals who do not need institutional care, but who need nursing services or therapy, medical supplies and special outpatient services.
A health care facility that provides supportive care for the terminally ill.
An institution whose primary function is to provide diagnostic and therapeutic inpatient services, for a variety of surgical and non-surgical medical conditions. In addition, most hospitals provide outpatient services, including emergency care.