Treatment Planning & Protocols Flashcards
7 cards from real CDC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Treatment Planning & Protocols flashcards as text
A consultant reviews a claim for a root canal treatment on tooth #14 along with a concurrent claim for extraction of tooth #14 submitted by a different provider on the same date. What is the appropriate action?
Answer: Investigate the conflicting claims as potentially duplicative and request clarification before paying
Conflicting services on the same tooth and date require investigation to determine which treatment was actually rendered before payment is issued.
When applying the 'reasonable and customary' (R&C) standard to evaluate a dental claim, which percentile of the fee distribution is most commonly used as the benchmark?
Answer: 75th percentile
The 75th percentile of fee distributions for a geographic area is the most commonly used R&C benchmark in dental benefits.
A treatment plan includes multiple restorations on the same tooth: an existing MOD composite and a proposed DO amalgam on tooth #30. Which review issue does this most likely present?
Answer: Overlapping surface restorations may indicate tooth preparation consolidation that should be reviewed for a single crown
Multiple restorations covering most of a posterior tooth's surfaces may indicate that a single crown is clinically more appropriate than separate restorations.
A provider requests prior authorization for an implant-supported fixed denture (All-on-4) for a fully edentulous patient. The patient's plan covers conventional complete dentures. Which approach best reflects proper claims adjudication?
Answer: Apply the alternative benefit provision and pay up to the conventional complete denture benefit level
When a plan covers a conventional denture as the alternative, the LCA/alternative benefit provision limits the benefit to the conventional denture fee.
A dental consultant is asked to review a treatment plan that was developed without any diagnostic radiographs. What is the most significant concern with this treatment plan?
Answer: The absence of radiographs means the treatment plan lacks essential diagnostic information to verify clinical necessity
Radiographs are a foundational diagnostic tool; their absence leaves the clinical basis for the treatment plan unsubstantiated.
A patient's dental treatment plan includes a fixed bridge on teeth #3-#5. Tooth #4 was extracted two years ago, and the plan covers bridges but has a five-year waiting period for major restorative services. The member enrolled two years ago. What is the correct benefit determination?
Answer: Deny the bridge because the five-year waiting period for major restorative services has not been satisfied
Waiting periods for major services must be fully satisfied; two years of enrollment does not meet a five-year waiting period requirement.
When evaluating a treatment plan, a dental consultant determines that the proposed treatment is clinically appropriate but not covered under the member's benefit plan. What is the correct action?
Answer: Deny the claim and inform the member of their appeal rights and any out-of-pocket options
Clinical appropriateness does not override plan exclusions; the claim should be denied per plan terms with proper member notification of appeal rights.