CDC Billing & Insurance Procedures 3 — Questions and Answers
Question 1: A claim is denied with the reason 'procedure not a covered benefit.' What is the most appropriate next step?
- Write off the balance immediately
- Review the patient's policy to confirm the denial is accurate, then appeal if warranted (Correct answer)
- Rebill the claim with a different CDT code
- Transfer the entire balance to the patient without review
Correct answer: Review the patient's policy to confirm the denial is accurate, then appeal if warranted
The coder should verify the denial reason against the patient's actual policy language before deciding to appeal or write off, ensuring accurate billing.
Question 2: Under HIPAA, the standard electronic transaction code set for dental claims is:
- X12 837D (Correct answer)
- X12 835
- X12 270/271
- ANSI 999
Correct answer: X12 837D
The X12 837D (Dental) transaction set is the HIPAA-mandated standard for electronic dental claim submissions.
Question 3: A patient's plan pays 80% after the deductible for basic services. The allowed fee for a restoration is $200 and the annual deductible of $50 has not been met. How much does insurance pay?
- $160
- $120 (Correct answer)
- $150
- $80
Correct answer: $120
After applying the $50 deductible, the remaining $150 is subject to 80% coverage: $150 × 0.80 = $120.
Question 4: Which term describes the provision that requires a patient to use in-network providers or face reduced or no benefits?
- Coordination of benefits
- Exclusion clause
- Network restriction / closed panel (Correct answer)
- Waiting period
Correct answer: Network restriction / closed panel
A closed-panel or network-restriction provision limits coverage to in-network providers, reducing or eliminating benefits for out-of-network care.
Question 5: A dental office submits a claim for D2750 (porcelain-fused-to-metal crown) but the insurer pays as if it were D2710 (resin-based composite crown) due to a 'least expensive alternative treatment' clause. This is called:
- Downcoding (Correct answer)
- Unbundling
- Upcoding
- Bundling
Correct answer: Downcoding
Downcoding occurs when the insurer reimburses at a lower code than what was billed because the plan only covers the least expensive treatment alternative.
Question 6: What information is required in Box 35 of the ADA Dental Claim Form?
- Patient's date of birth
- Treating dentist's NPI number
- Remarks or special conditions (Correct answer)
- Place of treatment code
Correct answer: Remarks or special conditions
Box 35 of the ADA Dental Claim Form is reserved for remarks, special notes, or conditions relevant to the claim.
Question 7: Which of the following is an example of unbundling in dental billing?
- Billing D2160 for an amalgam restoration instead of D2150
- Billing D4341 and D4342 separately when a full-mouth debridement D4355 was performed (Correct answer)
- Billing a single D2740 crown for both the preparation and final delivery
- Submitting a predetermination before a complex surgical procedure
Correct answer: Billing D4341 and D4342 separately when a full-mouth debridement D4355 was performed
Unbundling is billing multiple separate codes for a procedure that should be reported under one comprehensive code, such as using D4341/D4342 when D4355 applies.
CDC Billing & Insurance Procedures 3
A claim is denied with the reason 'procedure not a covered benefit.' What is the most appropriate next step?