CDC Billing & Insurance Procedures 2 — Questions and Answers
Question 1: A patient's dental plan has a $1,500 annual maximum and they have already used $1,200. The treatment plan totals $600. What is the maximum the insurance will pay?
- $600
- $300 (Correct answer)
- $1,500
- $400
Correct answer: $300
The remaining annual maximum is $1,500 − $1,200 = $300, so insurance will pay no more than $300 regardless of the total treatment cost.
Question 2: Which form is the standard claim form used to submit dental insurance claims electronically and on paper?
- CMS-1500
- ADA Dental Claim Form (Correct answer)
- UB-04
- HCFA-1450
Correct answer: ADA Dental Claim Form
The ADA Dental Claim Form (J400) is the standard used for both paper and electronic dental insurance submissions.
Question 3: A patient presents with a 'missing tooth clause' in their policy. What does this mean for CDT code D6010 (implant placement)?
- The implant is automatically covered at 100%
- The implant may be excluded because the tooth was missing before the policy effective date (Correct answer)
- The patient receives a higher benefit for implants
- The missing tooth clause only applies to bridges, not implants
Correct answer: The implant may be excluded because the tooth was missing before the policy effective date
A missing tooth clause excludes coverage for teeth that were already missing when the current policy became effective.
Question 4: When a dental office participates in a PPO network, the contractual adjustment on an EOB represents:
- The patient's copayment amount
- The difference between the billed fee and the contracted fee (Correct answer)
- The insurance company's profit margin
- The deductible applied to the claim
Correct answer: The difference between the billed fee and the contracted fee
The contractual adjustment (write-off) is the amount the provider agrees to discount per their PPO contract, equal to the billed fee minus the allowed/contracted fee.
Question 5: Which of the following best describes 'dual coverage' coordination of benefits?
- A patient covered by two dental plans where benefits are coordinated to avoid overpayment (Correct answer)
- A single plan that covers both dental and medical expenses
- Two deductibles applied simultaneously to one claim
- A patient who visits two different dental offices in the same year
Correct answer: A patient covered by two dental plans where benefits are coordinated to avoid overpayment
Dual coverage COB occurs when a patient has two dental insurance plans; the two insurers coordinate so that total reimbursement does not exceed 100% of the actual charges.
Question 6: A predetermination of benefits is submitted before treatment begins. What is the primary purpose of this process?
- To guarantee payment from the insurer
- To obtain an estimate of covered benefits before incurring the cost of treatment (Correct answer)
- To waive the patient's deductible
- To expedite claim processing after treatment is rendered
Correct answer: To obtain an estimate of covered benefits before incurring the cost of treatment
A predetermination gives the provider and patient an advance estimate of what the insurer will cover, though it is not a guarantee of payment.
Question 7: Which CDT code range covers diagnostic services that are commonly submitted on dental insurance claims?
- D0100–D0999 (Correct answer)
- D1000–D1999
- D9000–D9999
- D2000–D2999
Correct answer: D0100–D0999
CDT codes in the D0100–D0999 range cover diagnostic services, including examinations and radiographs.
CDC Billing & Insurance Procedures 2
A patient's dental plan has a $1,500 annual maximum and they have already used $1,200.
The treatment plan totals $600.
What is the maximum the insurance will pay?