Utilization Management & Peer Review 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 Utilization Management & Peer Review flashcards as text
What is the 'least costly alternative' principle in dental utilization management?
Answer: Authorizing the least expensive clinically appropriate treatment that adequately meets the patient's needs
The least costly alternative principle involves authorizing the least expensive clinically appropriate option that adequately addresses the patient's dental condition.
Under most state prompt payment regulations, within how many days must an insurer pay a clean dental claim?
Answer: 30 calendar days
Most state regulations require insurers to pay clean claims within 30 days of receipt, though exact timeframes vary by jurisdiction.
In peer review, what term describes the evaluation of whether a dental procedure was clinically indicated for the patient?
Answer: Clinical appropriateness determination
A clinical appropriateness determination evaluates whether the dental procedure was indicated based on the patient's clinical condition and established evidence-based criteria.
Which type of dental review program analyzes provider billing patterns to identify potential overutilization?
Answer: Retrospective data and practice pattern analysis
Retrospective data analysis examines historical billing patterns across providers to identify potential overutilization, fraud, or aberrant practice patterns.
What is an 'Independent Dental Examination' (IDE)?
Answer: A review by a neutral third-party dentist to provide an objective evaluation of disputed clinical findings
An Independent Dental Examination (IDE) is performed by a neutral, third-party dentist to provide an objective evaluation of disputed clinical findings or questions of treatment necessity.
Which criterion is MOST important when a dental consultant reviews a prior authorization request for a dental implant?
Answer: Documentation that the tooth is non-restorable and that an implant is the clinically appropriate replacement option
The primary criterion for implant authorization is documentation that the tooth is non-restorable and that a dental implant is the clinically appropriate tooth replacement option.
What does 'evidence-based dentistry' mean in the context of dental utilization review?
Answer: Integrating the best available research evidence with clinical expertise and patient values to guide decisions
Evidence-based dentistry integrates the best available scientific research with clinical expertise and patient values to guide treatment and coverage decisions.