Utilization Management & Peer Review 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 Utilization Management & Peer Review flashcards as text
What is the primary goal of dental utilization management?
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.
In prospective utilization review, when does the evaluation occur?
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.
Which organization publishes and maintains the CDT (Current Dental Terminology) code set?
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.
What is 'retrospective review' in dental utilization management?
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.
Which of the following best defines 'medical necessity' in dental utilization management?
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.
What does 'concurrent review' involve in dental utilization management?
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.
Which is the most appropriate basis for a dental consultant's coverage determination?
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.