Billing & Insurance Procedures Flashcards
7 cards from real CDC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Billing & Insurance Procedures flashcards as text
A patient's dental plan has a $1,500 annual maximum and they have already used $1,200. The treatment plan totals $600. What is the maximum the insurance will pay?
Answer: $300
The remaining annual maximum is $1,500 − $1,200 = $300, so insurance will pay no more than $300 regardless of the total treatment cost.
Which form is the standard claim form used to submit dental insurance claims electronically and on paper?
Answer: ADA Dental Claim Form
The ADA Dental Claim Form (J400) is the standard used for both paper and electronic dental insurance submissions.
A patient presents with a 'missing tooth clause' in their policy. What does this mean for CDT code D6010 (implant placement)?
Answer: The implant may be excluded because the tooth was missing before the policy effective date
A missing tooth clause excludes coverage for teeth that were already missing when the current policy became effective.
When a dental office participates in a PPO network, the contractual adjustment on an EOB represents:
Answer: The difference between the billed fee and the contracted fee
The contractual adjustment (write-off) is the amount the provider agrees to discount per their PPO contract, equal to the billed fee minus the allowed/contracted fee.
Which of the following best describes 'dual coverage' coordination of benefits?
Answer: A patient covered by two dental plans where benefits are coordinated to avoid overpayment
Dual coverage COB occurs when a patient has two dental insurance plans; the two insurers coordinate so that total reimbursement does not exceed 100% of the actual charges.
A predetermination of benefits is submitted before treatment begins. What is the primary purpose of this process?
Answer: To obtain an estimate of covered benefits before incurring the cost of treatment
A predetermination gives the provider and patient an advance estimate of what the insurer will cover, though it is not a guarantee of payment.
Which CDT code range covers diagnostic services that are commonly submitted on dental insurance claims?
Answer: D0100–D0999
CDT codes in the D0100–D0999 range cover diagnostic services, including examinations and radiographs.