CDC Regulatory Compliance & Risk Management 3 — Questions and Answers
Question 1: Under the ADA's Code of Ethics, a dental consultant who also maintains a private practice has a duty to:
- Prioritize the plan's financial interests over all ethical obligations
- Disclose conflicts of interest and recuse themselves from decisions where bias exists (Correct answer)
- Keep all plan review activities confidential from their professional licensing board
- Apply more stringent clinical standards to competing providers in the network
Correct answer: Disclose conflicts of interest and recuse themselves from decisions where bias exists
The ADA Code of Ethics requires dental professionals to disclose conflicts and avoid decisions where personal interest could bias professional judgment.
Question 2: The National Association of Dental Plans (NADP) recognizes which standard as the benchmark for dental claim transaction data exchange?
- HL7 FHIR R4
- HIPAA ASC X12 837D transaction set (Correct answer)
- NCPDP Telecom Standard
- CMS-1500 paper form only
Correct answer: HIPAA ASC X12 837D transaction set
The HIPAA-mandated ASC X12 837D electronic transaction set is the standard for submitting dental claims electronically.
Question 3: A group dental plan operating under ERISA is audited by the Department of Labor. The auditor's primary concern would be whether the plan:
- Has filed state insurance premium taxes correctly
- Is operating in accordance with its written plan document and ERISA fiduciary standards (Correct answer)
- Has obtained state licensure for each covered state
- Complies with state network adequacy regulations
Correct answer: Is operating in accordance with its written plan document and ERISA fiduciary standards
DOL ERISA audits focus on whether plan fiduciaries act prudently and in accordance with plan documents, not on state-level insurance requirements.
Question 4: A dental benefits consultant discovers that a plan administrator has been approving prior authorizations for a provider without clinical review. This violates which risk management principle?
- Actuarial equivalence
- Utilization management integrity and medical necessity standards (Correct answer)
- Coordination of benefits subrogation rights
- COBRA election period requirements
Correct answer: Utilization management integrity and medical necessity standards
Approving prior authorizations without clinical review undermines utilization management integrity and exposes the plan to liability for medically unnecessary expenditures.
Question 5: Which best describes the dental consultant's role when a provider appeals a claim denial on the grounds that the procedure was medically necessary?
- The consultant should automatically overturn the denial to avoid litigation risk
- The consultant should conduct a clinical review of submitted records using evidence-based criteria (Correct answer)
- The consultant should refer the dispute directly to the state insurance commissioner
- The consultant may deny the appeal without reviewing documentation if the original denial was valid
Correct answer: The consultant should conduct a clinical review of submitted records using evidence-based criteria
A proper appeal response requires the consultant to perform a clinical review of submitted documentation against evidence-based medical necessity criteria.
Question 6: The HIPAA Security Rule requires dental plans to conduct a risk analysis. The primary purpose of this analysis is to:
- Determine the premium rates for cyber liability insurance
- Identify and assess potential threats and vulnerabilities to electronic PHI (Correct answer)
- Satisfy IRS reporting requirements for health plan deductions
- Establish billing error rates for CMS benchmarking
Correct answer: Identify and assess potential threats and vulnerabilities to electronic PHI
The HIPAA Security Rule mandates a risk analysis to identify threats and vulnerabilities to ePHI so that appropriate safeguards can be implemented.
Question 7: A Medicaid dental managed care organization (DMCO) must comply with federal managed care regulations under 42 CFR Part 438. Which element is specifically required regarding network adequacy?
- All dental providers must be located within 5 miles of every enrollee
- The DMCO must meet time-and-distance standards for primary dental care access (Correct answer)
- Enrollees must have unlimited out-of-network access at in-network cost-sharing
- Network adequacy is determined solely by state credentialing standards
Correct answer: The DMCO must meet time-and-distance standards for primary dental care access
42 CFR Part 438 requires Medicaid managed care organizations to meet time-and-distance access standards to ensure geographic adequacy of provider networks.
CDC Regulatory Compliance & Risk Management 3
Under the ADA's Code of Ethics, a dental consultant who also maintains a private practice has a duty to: