CDC Billing & Insurance Procedures 3

Question 1

A claim is denied with the reason 'procedure not a covered benefit.' What is the most appropriate next step?

Accepted Answer

Review the patient's policy to confirm the denial is accurate, then appeal if warranted

Answer

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:

Accepted Answer

X12 837D

Answer

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?

Accepted Answer

$120

Answer

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?

Accepted Answer

Network restriction / closed panel

Answer

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:

Accepted Answer

Downcoding

Answer

Downcoding occurs when the insurer reimburses at a lower code than what was billed because the plan only covers the least expensive treatment alternative.

(CDC) Certified Dental Coder Practice Test

(CDC) Certified Dental Coder Practice Test

CDC Billing & Insurance Procedures 3