CDC Utilization Management & Peer Review

Question 1

What is the primary goal of dental utilization management?

Accepted Answer

To ensure dental services are medically necessary, appropriate, and cost-effective

Answer

To maximize dental insurance reimbursements for providers

Answer

To reduce patient access to elective dental care

Answer

To standardize dental fees across all geographic regions

Question 2

In prospective utilization review, when does the evaluation occur?

Accepted Answer

Before the dental service is rendered

Answer

After the service has been rendered and billed

Answer

While the service is actively being performed

Answer

Six months following completion of treatment

Question 3

Which organization publishes and maintains the CDT (Current Dental Terminology) code set?

Accepted Answer

American Dental Association (ADA)

Answer

Centers for Medicare & Medicaid Services (CMS)

Answer

American Medical Association (AMA)

Answer

National Dental Association (NDA)

Question 4

What is 'retrospective review' in dental utilization management?

Accepted Answer

Review conducted after dental services have already been provided

Answer

Review conducted before treatment authorization is granted

Answer

Review conducted during an ongoing course of treatment

Answer

Review of a provider's future treatment plans

Question 5

Which of the following best defines 'medical necessity' in dental utilization management?

Accepted Answer

Treatment that is clinically appropriate, necessary to meet the patient's dental needs, and not solely for convenience

Answer

Any treatment that a licensed dentist recommends to a patient

Answer

Any treatment that is covered under a dental insurance plan

Answer

Treatment that represents the most advanced option available

Question 6

What does 'concurrent review' involve in dental utilization management?

Accepted Answer

Evaluating the appropriateness of ongoing treatment during its course

Answer

Reviewing claims from multiple providers at the same time

Answer

Comparing dental fee schedules across multiple benefit plans

Answer

Reviewing treatment records after final payment has been issued

Question 7

Which is the most appropriate basis for a dental consultant's coverage determination?

Accepted Answer

Evidence-based clinical criteria and the dental benefit plan's contract language

Answer

The treating provider's established fee schedule

Answer

The patient's personal preference for treatment

Answer

The geographic region in which the provider practices