CDC Utilization Management & Peer Review 2

Question 1

What is the 'least costly alternative' principle in dental utilization management?

Accepted Answer

Authorizing the least expensive clinically appropriate treatment that adequately meets the patient's needs

Answer

Paying the lowest claim amount regardless of clinical necessity

Answer

Requiring patients to always choose the cheapest dental provider available

Answer

Denying all claims that exceed a predetermined dollar threshold

Question 2

Under most state prompt payment regulations, within how many days must an insurer pay a clean dental claim?

Accepted Answer

30 calendar days

Answer

10 calendar days

Answer

90 calendar days

Answer

60 calendar days

Question 3

In peer review, what term describes the evaluation of whether a dental procedure was clinically indicated for the patient?

Accepted Answer

Clinical appropriateness determination

Answer

Fiscal intermediary review

Answer

Fee schedule analysis

Answer

Benefit limit assessment

Question 4

Which type of dental review program analyzes provider billing patterns to identify potential overutilization?

Accepted Answer

Retrospective data and practice pattern analysis

Answer

Prospective pre-authorization review

Answer

Concurrent treatment monitoring

Answer

Independent dental examination

Question 5

What is an 'Independent Dental Examination' (IDE)?

Accepted Answer

A review by a neutral third-party dentist to provide an objective evaluation of disputed clinical findings

Answer

An examination conducted by the treating dentist specifically for insurance billing purposes

Answer

An annual preventive exam required by all dental benefit plans

Answer

An examination required before any referral to a dental specialist

Question 6

Which criterion is MOST important when a dental consultant reviews a prior authorization request for a dental implant?

Accepted Answer

Documentation that the tooth is non-restorable and that an implant is the clinically appropriate replacement option

Answer

The patient's stated cosmetic preferences for tooth replacement

Answer

A cost comparison between an implant and leaving the space edentulous

Answer

The number of years the dentist has been placing implants

Question 7

What does 'evidence-based dentistry' mean in the context of dental utilization review?

Accepted Answer

Integrating the best available research evidence with clinical expertise and patient values to guide decisions

Answer

Using only the most expensive and technologically advanced treatment options

Answer

Relying solely on the treating dentist's clinical opinion and experience

Answer

Following treatment protocols established in the 1980s and 1990s