CDC Regulatory Compliance & Risk Management 5

Question 1

Under the No Surprises Act (as applied to dental benefits), the primary protection for patients involves:

Accepted Answer

Limiting unexpected balance billing by out-of-network providers in specific emergency and facility settings

Answer

The No Surprises Act protects patients from unexpected out-of-network bills primarily in emergency and certain facility-based settings, limiting balance billing.

Question 2

A dental plan's Explanation of Benefits (EOB) must, at minimum, include which element to comply with ERISA disclosure requirements?

Accepted Answer

The specific reason for any denial and instructions on how to appeal

Answer

ERISA requires EOBs to include the reason for any adverse benefit determination and instructions for initiating the plan's appeals process.

Question 3

In dental risk management, the term 'tail coverage' in a professional liability context refers to:

Accepted Answer

Malpractice coverage for claims filed after a claims-made policy has ended for incidents during the policy period

Answer

Tail coverage (extended reporting endorsement) covers claims reported after a claims-made policy ends for incidents that occurred during the active policy period.

Question 4

A dental benefits organization seeking URAC accreditation for its dental utilization management program must demonstrate that clinical reviewers are:

Accepted Answer

Licensed dentists or other qualified dental professionals appropriate to the clinical issue under review

Answer

URAC UM accreditation requires that clinical review decisions be made by professionals with appropriate dental credentials matched to the clinical content of the review.

Question 5

A dental consultant discovers that a provider's claim submission contains altered radiographic images. The most appropriate immediate action is to:

Accepted Answer

Suspend the claim, document findings, and refer to the Special Investigations Unit (SIU) or fraud unit

Answer

Altered documentation is a serious fraud indicator requiring immediate claim suspension and referral to the SIU for formal investigation.

(CDC) Certified Dental Consultant Practice Test

(CDC) Certified Dental Consultant Practice Test

CDC Regulatory Compliance & Risk Management 5