Commonly Used Terms

Allowed Amount
The dollar amount used to calculate payment by VADIP based on the coverage percentage for the service(s) submitted on the claim.
Annual Maximum Benefit
The total dollar amount that can be paid by VADIP per subscriber during each benefit year.
Appeal
A formal procedure through which a subscriber in VADIP or an authorized representative can request a review of the denial of payment of a claim for covered dental services.
Appealable Issue
An issue regarding the denial of payment of a claim for covered dental services for reasons other than those involving the rules and policies of VADIP as set forth by law or regulation.
Approved Amount
The approved amount is the dollar amount used to calculate the total cost share due for the service(s) submitted on the claim.
Assignment of Benefits
This term refers to the authorization that a primary subscriber gives Delta Dental, by signing the appropriate section on the claim form, to send payment for any VADIP covered services directly to the non-Delta Dental treating dentist.
Basic Services
The most commonly needed dental services to help maintain good dental health. These services include those dental procedures necessary to restore the teeth (other than cast crowns and cast restorations), oral surgery procedures such as extractions, endodontic procedures such as root canals, and periodontal procedures including gum surgery.
Benefits
Dental services/procedures received by a subscriber for which all or part of the cost is paid under VADIP.
Benefits Booklet
A comprehensive, detailed explanation of the policies and benefits of VADIP.
Benefit Year
The time period (usually 12 months) to which each subscriber’s deductibles, maximums and other plan provisions are applied.
Calendar Year
The 12-month period beginning January 1 and ending December 31. VADIP does not use a calendar year to determine annual benefits.
Claim Form
A standard form submitted by the dentist or patient to Delta Dental for reimbursement of dental services. The completed and signed form must contain the information necessary for consideration for payment of dental services.
Code on Dental Procedures and Nomenclature
A coding structure developed by the American Dental Association (ADA) to achieve uniformity, consistency and specificity throughout the dental industry in accurately reporting dental treatment. The code has been designated as the national standard for reporting dental services by the federal government under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and is currently recognized by dental insurance companies nationwide. The benefits booklet uses the most current version of the code at the time of printing.
Comprehensive Oral Examination
A thorough evaluation of the extra-oral and intraoral hard and soft tissues and detailed recording of the findings. It may require interpretation of information acquired through additional diagnostic procedures. A comprehensive evaluation typically includes an evaluation and recording of the patient’s dental and medical history and a general health assessment, as well as an evaluation and recording of dental caries, missing or unerupted teeth, restorations, occlusal (bite) relations, periodontal conditions (including periodontal charting), hard and soft tissue abnormalities, etc.
Contract
The written agreement between the Department of Veterans Affairs and Delta Dental of California to administer a program of dental benefits established by the U.S. Government for eligible Veterans and CHAMPVA beneficiaries. In addition to the laws and regulations governing VADIP, the contract, together with this benefits booklet, forms the terms and conditions of the benefits provided under VADIP.
Coordination of Benefits (COB)
A method of integrating benefits payable for the same patient under more than one dental plan. Benefits from all sources should not exceed 100% of the total charges.
Copayment/Cost Share
The subscriber’s portion of the allowed fee for a covered procedure.
Coverage Effective Date
The date a VADIP subscriber may begin obtaining benefits. The coverage effective date is the first day of the month following receipt and acceptance of the enrollment application.
Covered Procedure/Service
A dental procedure or service provided and/or received in accordance with the policies of VADIP for which benefit payment will be made by Delta Dental.
Date of Service
The date a dental service was completed. In cases when more than one visit is necessary to complete a dental procedure, the date that the actual procedure is completed is considered the date of service. This is the date that should be indicated on the claim form when it is submitted for payment.
Deductible
The dollar amount that must be paid by the patient towards some covered services before the VADIP payment is applied to those services.
Delta Dental of California
A not-for-profit dental benefits administrator, Delta Dental of California is one of many Delta Dental Plans across the country that are members of Delta Dental Plans Association. Delta Dental of California administers VADIP through its subsidiary, Delta Dental Insurance Company.
Diagnostic Services
Procedures performed by the dentist to identify the health of the teeth and supporting structures and areas in and around the mouth. The most common diagnostic procedures are examinations and x-rays.
Dual Coverage
When a subscriber has coverage for dental care under more than one benefit (insurance) plan.
Eligibility
The criteria set forth by the Department of Veterans Affairs to determine who is allowed to enroll in VADIP.
Endodontic Services
Dental services that involve the treatment of diseases or injuries that affect the nerve and blood supply of a tooth. A common endodontic procedure is root canal therapy.
Enrollment Grace Period
A period of 30 days from your coverage effective date during which time you may dis-enroll, provided you or any CHAMPVA beneficiary have not used any of the benefits of VADIP.
Exclusions
Dental services and/or procedures not covered under VADIP.
Explanation of Benefits (EOB)
A statement sent to the primary subscriber and to the dentist, when the dentist is paid directly by Delta Dental, showing dentist and patient information, the service(s) received, the allowable charge(s), the amount(s) billed, the amount(s) allowed by the program and the cost-share amount(s). For denied services, the EOB also explains why payment was not allowed and how to appeal that decision.
Federal Government Programs
The division of Delta Dental of California that administers VADIP under a contract with the Department of Veterans Affairs.
Fee Schedule
A list of the charges agreed to by a dentist and the dental insurance company for specific dental services.
Grace Period
See Enrollment Grace Period.
Grievance
A formal procedure that offers an opportunity for aggrieved parties to seek and obtain an explanation for and/or correction of any perceived failure of a network dentist or Delta Dental personnel to furnish the level or quality of care and/or service to which the beneficiary believes he or she is entitled.
Maximum Benefit Amount
The total dollar amount per enrollee that Delta Dental will pay during a specific period of time for covered services as specified in VADIP’s contract provisions.
Network Dentist
A licensed dentist who is a member of a specific network of dentists who have agreed to accept negotiated fees for the provision of affordable dental care.
Oral Hygiene
The practice of personal hygiene of the mouth. It includes the maintenance of oral cleanliness, tissue tone, and general preservation of oral health through brushing and flossing.
Oral Surgery
Surgical procedures in and about the oral cavity and jaws, such as extractions.
Out-of-Network Dentist
A licensed dentist who is not a member of the participating VADIP network. While care may be received from an out-of-network dentist, subscribers may experience higher out-of-pocket costs than if using a participating network dentist.
Overbilling
The unethical practice whereby a dentist may offer to forego collection of a patient’s copayment as required by VADIP and to accept the program’s “covered” percentage as payment in full. Overbilling by dentists is illegal and leads to increased costs for dental care and limits access to affordable dental coverage under programs such as VADIP.
Participating Network Dentist
A licensed dentist who “participates” in the network that supports VADIP by agreeing to accept the program allowable fees as the full fee for covered treatment, complete and submit claims paperwork on behalf of the VADIP patient, and receive payment directly from Delta Dental. See Network Dentist.
Periodontal Services
Services that involve the treatment of diseases of the gum or supporting structure (bone). A common periodontal service is a periodontal root planing.
Pre-treatment
A non-binding, written estimate by Delta Dental of how much VADIP will cover for a particular service. Pre-treatment requests from dentists are suggested for the more complicated and expensive treatments plans.
Premium
The monthly amount paid by a subscriber for coverage under VADIP.
Premium Prepayment
An advance payment amounting to the first month’s premium that is required to be made at the time of application for enrollment in VADIP. Future monthly premiums are paid through electronic funds transfer (EFT).
Preventive Services
Dental services performed to prevent tooth decay and gum disease. Common preventive services include cleanings and fluoride treatments.
Procedure Codes
The American Dental Association (ADA) codes used to identify and define specific dental services. Only those dental services whose procedure codes are specifically listed in this benefits booklet are covered under VADIP.
Prosthodontic Services
Dental services that involve the design, construction and fitting of fixed bridges and partial and complete dentures to replace missing teeth or restore oral structures.
Provider
A dentist or other person who is licensed by a state to deliver dental services.
Service Area
The area in which enrollees may obtain dental treatment that is covered under VADIP includes all 50 U.S. states, the District of Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa and the Commonwealth of the Northern Mariana Islands.
Restorative Services
Dental procedures performed to restore the missing part of the tooth that was due to decay or fracture. A common restorative service is an amalgam (silver) filling.
Submitted Amount
The amount normally charged by the dentist for services provided to all patients, regardless of insurance coverage.
Universal/National Tooth Numbering System
A system that assigns a unique number (1-32) to permanent teeth and a unique letter (A-T) to primary teeth.
Waiting Period
The specific period of time of continuous enrollment that a subscriber in VADIP must complete before applicable dental procedures become covered benefits.

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