Billing & Insurance Procedures Flashcards

Which of the following describes 'fee-for-service' dental insurance?

Answer: The insurer pays the provider a set fee for each covered procedure after it is performed

Fee-for-service (indemnity) plans reimburse the provider or patient a set amount per procedure code after treatment is rendered.

A 'capitation' arrangement in a dental HMO means the dentist is paid:

Answer: A fixed monthly amount per enrolled patient regardless of services provided

Capitation is a flat monthly payment per assigned patient (per member per month), paid regardless of how many or how few services the patient uses.

When a patient has Medicaid as their secondary insurance and a private plan as primary, the dental coder should:

Answer: Submit to the private plan first; submit the EOB with the Medicaid claim as secondary

Medicaid is almost always payer of last resort; the claim must go to the primary private insurer first, and the resulting EOB is submitted with the Medicaid claim.

The timely filing limit for a dental claim is important because:

Answer: Submitting after the deadline results in denial that typically cannot be appealed or overridden

Most insurers enforce strict timely filing deadlines (e.g., 90 days to 12 months); claims submitted after the deadline are denied and the provider generally cannot bill the patient for this administrative error.

On a dental claim, the 'place of treatment' code '11' indicates:

Answer: Office (private dental practice)

Place of service/treatment code 11 designates an office setting, which is the standard location for routine private dental practice.

Which of the following is an accurate description of a 'table of allowances' benefit plan?

Answer: The plan pays a fixed dollar amount per procedure regardless of the dentist's actual fee

A table of allowances plan assigns a predetermined fixed dollar amount to each procedure code; any amount above that allowance is the patient's responsibility.

A dental office receives an EOB showing 'patient not eligible on date of service.' The best first step is to:

Answer: Contact the insurer to verify the patient's eligibility retroactively and confirm the correct policy effective date

Before any further action, the coder should verify eligibility directly with the insurer, as eligibility data can sometimes be incorrect or lag in the system.