Regulatory Compliance & Risk Management 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 Regulatory Compliance & Risk Management flashcards as text
A dental plan member files a complaint alleging that a coverage denial violated the plan's internal grievance procedures. Under ERISA Section 503, the plan must:
Answer: Provide a full and fair review of the denied claim with written notice of the determination
ERISA Section 503 mandates that plans provide a full and fair review of any denied claim and furnish written explanation of the determination.
When evaluating a claim for a dental implant, a consultant notes the plan excludes 'osseointegrated implants' but the provider billed for 'endosteal implant.' The correct approach is:
Answer: Evaluate whether the billed procedure is clinically equivalent to the excluded service regardless of terminology
Consultants must assess clinical equivalence, not just terminology, to apply plan exclusions fairly and consistently.
A dental plan operating in multiple states must ensure its utilization management programs comply with:
Answer: URAC accreditation standards and each state's UM regulations where it operates
Fully insured plans must comply with UM regulations in each state where they operate, and URAC accreditation provides a recognized compliance framework.
A fraud investigator refers a case to a dental consultant involving a provider who billed for 'complete denture' but delivered 'immediate denture.' This scenario most likely involves:
Answer: Misrepresentation of services rendered, a form of dental fraud
Billing for a service not actually delivered constitutes misrepresentation of services rendered, which is a form of dental insurance fraud.
The ADA's CDT code set is updated annually. From a regulatory compliance standpoint, dental plans must:
Answer: Implement updated CDT codes by January 1 of the effective year to remain compliant
HIPAA requires use of current CDT code sets, and plans must implement annual updates by the effective date to process claims correctly.
When a dental plan's network agreement with a provider group is terminated, the plan's risk management obligation includes:
Answer: Providing members adequate notice and ensuring continuity of care for members mid-treatment
Risk management best practices and many state regulations require member notification and continuity of care provisions when network providers are terminated.
A dental consultant reviewing a Medicaid audit finds that a provider billed for services to a patient who was deceased on the date of service. This is classified as:
Answer: Fraud, constituting a false claim to a federal healthcare program
Billing for services to a deceased beneficiary constitutes submission of a false claim to a federal program, which is fraud subject to significant penalties.