CDC Billing & Insurance Procedures 2

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?

Accepted Answer

$300

Answer

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?

Accepted Answer

ADA Dental Claim Form

Answer

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)?

Accepted Answer

The implant may be excluded because the tooth was missing before the policy effective date

Answer

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:

Accepted Answer

The difference between the billed fee and the contracted fee

Answer

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?

Accepted Answer

A patient covered by two dental plans where benefits are coordinated to avoid overpayment

Answer

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.

(CDC) Certified Dental Coder Practice Test

(CDC) Certified Dental Coder Practice Test

CDC Billing & Insurance Procedures 2