CDC Utilization Management & Peer Review 3

Question 1

What is the primary purpose of 'frequency limitations' in a dental benefit plan?

Accepted Answer

To prevent overutilization of services that are clinically indicated only at defined intervals

Answer

To limit patient access to dental specialist referrals

Answer

To restrict patients to using a single dental provider per year

Answer

To cap the total number of dental procedures regardless of need

Question 2

Which term describes the review of a provider's overall treatment and billing trends compared to peers?

Accepted Answer

Practice pattern analysis

Answer

Individual claim adjudication

Answer

Prospective pre-authorization

Answer

Routine benefit determination

Question 3

When conducting a utilization review for periodontal disease, which radiographs are typically required to adequately evaluate bone loss?

Accepted Answer

Full mouth series (FMX) or current bitewing radiographs

Answer

Panoramic radiograph alone

Answer

Cephalometric radiograph

Answer

Occlusal radiograph series

Question 4

What is an 'alternative benefit provision' in dental plan administration?

Accepted Answer

A benefit that replaces the requested procedure with a less costly but clinically acceptable alternative

Answer

An additional benefit not typically covered under the primary dental plan

Answer

A provision for out-of-network reimbursement when in-network providers are unavailable

Answer

Emergency dental coverage available when the patient is traveling

Question 5

Which of the following scenarios most likely represents a non-covered 'cosmetic' dental service?

Accepted Answer

Choosing a tooth-colored composite resin over a functional amalgam on a posterior tooth at additional cost

Answer

Placement of a porcelain crown on a structurally compromised posterior molar

Answer

Full mouth reconstruction following documented traumatic injury

Answer

Periodontal surgical treatment for active advanced periodontal disease

Question 6

What does 'coordination of benefits' (COB) require a dental consultant to evaluate?

Accepted Answer

How benefits are applied when a patient is covered by more than one dental plan

Answer

Whether the patient has received a specialist referral prior to treatment

Answer

Whether the treating provider is participating in the plan's network

Answer

The maximum annual dollar benefit of the dental plan

Question 7

Which of the following best describes the role of a Certified Dental Consultant (CDC) during the appeals process?

Accepted Answer

CDCs apply dental clinical expertise to ensure appealed determinations are fair, objective, and based on established criteria

Answer

CDCs handle only first-level claim denials and do not participate in formal appeals

Answer

CDCs are required to reverse all initial denials when an appeal is submitted

Answer

CDCs determine insurance premium rates based on appeals volume