CDC Utilization Management & Peer Review 1 — Questions and Answers
Question 1: What is the primary goal of dental utilization management?
- To ensure dental services are medically necessary, appropriate, and cost-effective (Correct answer)
- To maximize dental insurance reimbursements for providers
- To reduce patient access to elective dental care
- To standardize dental fees across all geographic regions
Correct answer: To ensure dental services are medically necessary, appropriate, and cost-effective
Utilization management aims to ensure services are medically necessary, clinically appropriate, and cost-effective while maintaining quality of care.
Question 2: In prospective utilization review, when does the evaluation occur?
- After the service has been rendered and billed
- While the service is actively being performed
- Before the dental service is rendered (Correct answer)
- Six months following completion of treatment
Correct answer: Before the dental service is rendered
Prospective review occurs before the dental service is rendered to determine if it meets coverage criteria and is medically necessary.
Question 3: Which organization publishes and maintains the CDT (Current Dental Terminology) code set?
- Centers for Medicare & Medicaid Services (CMS)
- American Medical Association (AMA)
- American Dental Association (ADA) (Correct answer)
- National Dental Association (NDA)
Correct answer: American Dental Association (ADA)
The American Dental Association (ADA) publishes and annually updates the CDT code set used for dental procedure reporting and billing.
Question 4: What is 'retrospective review' in dental utilization management?
- Review conducted before treatment authorization is granted
- Review conducted during an ongoing course of treatment
- Review conducted after dental services have already been provided (Correct answer)
- Review of a provider's future treatment plans
Correct answer: Review conducted after dental services have already been provided
Retrospective review evaluates whether dental services that have already been rendered were medically necessary and clinically appropriate.
Question 5: Which of the following best defines 'medical necessity' in dental utilization management?
- Any treatment that a licensed dentist recommends to a patient
- Treatment that is clinically appropriate, necessary to meet the patient's dental needs, and not solely for convenience (Correct answer)
- Any treatment that is covered under a dental insurance plan
- Treatment that represents the most advanced option available
Correct answer: Treatment that is clinically appropriate, necessary to meet the patient's dental needs, and not solely for convenience
Medical necessity requires that treatment be clinically appropriate, necessary to address the patient's condition, and not performed solely for patient or provider convenience.
Question 6: What does 'concurrent review' involve in dental utilization management?
- Reviewing claims from multiple providers at the same time
- Evaluating the appropriateness of ongoing treatment during its course (Correct answer)
- Comparing dental fee schedules across multiple benefit plans
- Reviewing treatment records after final payment has been issued
Correct answer: Evaluating the appropriateness of ongoing treatment during its course
Concurrent review evaluates the necessity and appropriateness of dental treatment while it is actively ongoing, rather than before or after.
Question 7: Which is the most appropriate basis for a dental consultant's coverage determination?
- The treating provider's established fee schedule
- The patient's personal preference for treatment
- Evidence-based clinical criteria and the dental benefit plan's contract language (Correct answer)
- The geographic region in which the provider practices
Correct answer: Evidence-based clinical criteria and the dental benefit plan's contract language
Coverage determinations must be grounded in evidence-based clinical criteria combined with the specific language and limitations of the dental benefit plan contract.
CDC Utilization Management & Peer Review 1
What is the primary goal of dental utilization management?