CDC Utilization Management & Peer Review 2 — Questions and Answers
Question 1: What is the 'least costly alternative' principle in dental utilization management?
- Paying the lowest claim amount regardless of clinical necessity
- Authorizing the least expensive clinically appropriate treatment that adequately meets the patient's needs (Correct answer)
- Requiring patients to always choose the cheapest dental provider available
- Denying all claims that exceed a predetermined dollar threshold
Correct answer: Authorizing the least expensive clinically appropriate treatment that adequately meets the patient's needs
The least costly alternative principle involves authorizing the least expensive clinically appropriate option that adequately addresses the patient's dental condition.
Question 2: Under most state prompt payment regulations, within how many days must an insurer pay a clean dental claim?
- 10 calendar days
- 30 calendar days (Correct answer)
- 90 calendar days
- 60 calendar days
Correct answer: 30 calendar days
Most state regulations require insurers to pay clean claims within 30 days of receipt, though exact timeframes vary by jurisdiction.
Question 3: In peer review, what term describes the evaluation of whether a dental procedure was clinically indicated for the patient?
- Fiscal intermediary review
- Clinical appropriateness determination (Correct answer)
- Fee schedule analysis
- Benefit limit assessment
Correct answer: Clinical appropriateness determination
A clinical appropriateness determination evaluates whether the dental procedure was indicated based on the patient's clinical condition and established evidence-based criteria.
Question 4: Which type of dental review program analyzes provider billing patterns to identify potential overutilization?
- Prospective pre-authorization review
- Concurrent treatment monitoring
- Retrospective data and practice pattern analysis (Correct answer)
- Independent dental examination
Correct answer: Retrospective data and practice pattern analysis
Retrospective data analysis examines historical billing patterns across providers to identify potential overutilization, fraud, or aberrant practice patterns.
Question 5: What is an 'Independent Dental Examination' (IDE)?
- An examination conducted by the treating dentist specifically for insurance billing purposes
- A review by a neutral third-party dentist to provide an objective evaluation of disputed clinical findings (Correct answer)
- An annual preventive exam required by all dental benefit plans
- An examination required before any referral to a dental specialist
Correct answer: A review by a neutral third-party dentist to provide an objective evaluation of disputed clinical findings
An Independent Dental Examination (IDE) is performed by a neutral, third-party dentist to provide an objective evaluation of disputed clinical findings or questions of treatment necessity.
Question 6: Which criterion is MOST important when a dental consultant reviews a prior authorization request for a dental implant?
- The patient's stated cosmetic preferences for tooth replacement
- Documentation that the tooth is non-restorable and that an implant is the clinically appropriate replacement option (Correct answer)
- A cost comparison between an implant and leaving the space edentulous
- The number of years the dentist has been placing implants
Correct answer: Documentation that the tooth is non-restorable and that an implant is the clinically appropriate replacement option
The primary criterion for implant authorization is documentation that the tooth is non-restorable and that a dental implant is the clinically appropriate tooth replacement option.
Question 7: What does 'evidence-based dentistry' mean in the context of dental utilization review?
- Using only the most expensive and technologically advanced treatment options
- Relying solely on the treating dentist's clinical opinion and experience
- Integrating the best available research evidence with clinical expertise and patient values to guide decisions (Correct answer)
- Following treatment protocols established in the 1980s and 1990s
Correct answer: Integrating the best available research evidence with clinical expertise and patient values to guide decisions
Evidence-based dentistry integrates the best available scientific research with clinical expertise and patient values to guide treatment and coverage decisions.
CDC Utilization Management & Peer Review 2
What is the 'least costly alternative' principle in dental utilization management?