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 primary purpose of 'frequency limitations' in a dental benefit plan?
Answer: To prevent overutilization of services that are clinically indicated only at defined intervals
Frequency limitations prevent overutilization by restricting how often certain services such as prophylaxis or radiographs can be claimed within a defined time period, based on typical clinical need.
Which term describes the review of a provider's overall treatment and billing trends compared to peers?
Answer: Practice pattern analysis
Practice pattern analysis evaluates a provider's overall treatment and billing trends in comparison to peer providers to identify statistical outliers or potential overutilization.
When conducting a utilization review for periodontal disease, which radiographs are typically required to adequately evaluate bone loss?
Answer: Full mouth series (FMX) or current bitewing radiographs
A full mouth series (FMX) or updated bitewing radiographs are required to properly evaluate the extent and pattern of alveolar bone loss in periodontal disease.
What is an 'alternative benefit provision' in dental plan administration?
Answer: A benefit that replaces the requested procedure with a less costly but clinically acceptable alternative
An alternative benefit provision authorizes a less costly but clinically acceptable alternative procedure in place of the one requested, with the plan paying only for the alternative.
Which of the following scenarios most likely represents a non-covered 'cosmetic' dental service?
Answer: Choosing a tooth-colored composite resin over a functional amalgam on a posterior tooth at additional cost
When a tooth-colored composite is chosen over a clinically functional amalgam restoration on a posterior tooth, the additional cost for the cosmetic preference is typically not a covered dental benefit.
What does 'coordination of benefits' (COB) require a dental consultant to evaluate?
Answer: How benefits are applied when a patient is covered by more than one dental plan
Coordination of benefits (COB) requires evaluating how multiple dental plans interact so that combined payments from all plans do not exceed 100% of the actual dental charges.
Which of the following best describes the role of a Certified Dental Consultant (CDC) during the appeals process?
Answer: CDCs apply dental clinical expertise to ensure appealed determinations are fair, objective, and based on established criteria
A CDC provides clinical expertise during the appeals process to ensure determinations are fair, objective, and supported by established clinical criteria and the terms of the benefit plan.