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 'waiting period' in a dental insurance policy typically means:
Answer: A specific period after the policy effective date during which certain benefits are not covered
A waiting period is a defined span (e.g., 6–12 months) after policy inception during which certain services—often major procedures—are not yet covered.
When a claim is submitted with an incorrect tooth number, the most likely denial reason code is:
Answer: Invalid or missing tooth number / tooth designation error
Tooth number errors cause claim rejections or denials because the insurer cannot validate the procedure against the patient's treatment history.
Which of the following best describes the 'birthday rule' used in COB for dependent children?
Answer: The parent born first in the calendar year has the primary plan for the child
Under the birthday rule, the plan of the parent whose birthday falls first in the calendar year is considered primary for dependent children.
An EOB lists the 'allowed amount' as $180 for a procedure billed at $250. The plan pays 80% of the allowed amount. What is the insurer's payment?
Answer: $144
80% of the allowed amount ($180) equals $144; the remaining $36 is the patient's coinsurance and the $70 difference from billed to allowed is a contractual write-off.
When submitting a claim for orthodontic treatment, the banding date is important because it:
Answer: Establishes when active treatment began and triggers benefit payment schedules
The banding date (placement of bands/brackets) is the start of active orthodontic treatment and determines the lifetime benefit, payment installments, and policy applicability.
Which action constitutes insurance fraud in dental billing?
Answer: Billing a procedure that was planned but not yet performed
Billing for a procedure that was not yet performed (or never performed) constitutes fraud, as it misrepresents services to obtain payment.
A claim is rejected as a 'duplicate.' The coder should first:
Answer: Verify whether the original claim was already paid, pending, or denied before taking further action
Before resubmitting a 'duplicate' claim, the coder must check the status of the original claim to avoid overpayment or creating a genuine duplicate.