Deck 15: Dental Insurance Processing

Question 1

A dental clinic provided by a large corporation for employees and their families is an example of what type of dental program?

A)Capitation program
B)Preferred provider organization
C)Franchise dentistry
D)Closed panel programs

Answer 1

Closed panel programs

Question 2

Which of the following statements is true?

A)The CDT manual is published by the CRC and is updated annually.
B)The first digit of a dental procedure code is the number "2."
C)A brief,literal definition precedes each dental procedure code.
D)The CDT manual is used principally to identify and define transaction codes.

Answer 2

The CDT manual is used principally to identify and define transaction codes.

Question 3

Where should copies of the Explanation of Benefits (EOB)be filed?

A)In the clinical records
B)In a file for the month in which the claim was billed
C)In a file for the specific insurance company
D)In a file for the month in which the claim was paid

Answer 3

In a file for the month in which the claim was paid

Question 4

Employers rarely change their dental coverage.A patient with the same company for 25 years will most likely have the same carrier and benefits for the duration of his/her employment.

A)The first statement is true;the second statement is false.
B)The first statement is false;the second statement is true.
C)Both statements are true.
D)Both statements are false.

Question 5

A new administrative dental assistant is learning to complete insurance claims.The claim she is processing is for a minor child who is covered under dental plans from both parents' employers.She asks whether you know which plan should be billed first.Using the Birthday Rule,what would you tell your colleague?

A)The father's insurance should be billed first if he is older than his wife.
B)The parent who has a birth date closest to that of the child is billed first.
C)The parent whose birthday comes first in the year is the primary insurance holder.
D)Call the parents and ask whom they would like you to bill first.

Question 6

When the usual fee charged by the dental practice is higher than the fee established in a(n)_______,the difference between fees cannot be charged to the patient.

A)fixed fee schedule
B)table of allowance
C)indemnity schedule
D)schedule of allowance

Question 7

Which of the following statements is false?

A)Patients with dual coverage do not get to decide who is going to be the primary carrier.
B)The primary carrier is always billed before the secondary carrier.
C)The gender rule assigns primary coverage to the mother when secondary coverage for children is determined.
D)The secondary insurance company will not pay more than the residual balance.

Question 8

Which method of payment sidesteps the insurance company by paying directly from a fund established by an employer?

A)Union trust fund
B)Direct reimbursement
C)Capitation program
D)Incentive program

Question 9

Fill in the blank: _______ is the set dollar amount that the patient must pay toward treatment before the third party will consider payment.

A)Policy coverage
B)The deductible
C)Coverage limitation
D)Eligibility

Question 10

A patient states that he has dental insurance through his employer and is also covered under his wife's plan.He asks whether both plans can be used to cover the full amount of the treatment.You know that the term that describes this process is:

A)Consolidated Omnibus Budget Reconciliation Act (COBRA).
B)coordination of benefits (COB).
C)dependent coverage.
D)assignment of benefits.

Question 11

Usual,customary,or reasonable charges include criteria that may be used to establish a fee schedule.A patient asks you to explain "reasonable fee." Which of the following would be a proper explanation?

A)The fee the dentist uses most often for a given dental procedure
B)Determination by a third party administrator that a particular service for a given procedure has been modified to take into consideration unusual complications
C)The fee determined by a third party administrator for actual submitted fees for specific dental services
D)Fees set by the insurance company without consideration of geographic location and demographic information

Question 12

A correctly completed dental claim form will contain all information requested for each data item.The administrative dental assistant can obtain this information from the:

A)patient before treatment.
B)patient after treatment.
C)patient's clinical chart.
D)member of the dental team who is providing treatment.

Question 13

A patient is being seen after a work-related accident in which several of his teeth were broken.How will his treatment be billed?

A)To his primary insurance
B)Workers' compensation
C)Government assistance
D)Secondary coverage

Question 14

Maximum coverage can be described as:

A)a set dollar amount that the patient must pay each year before insurance benefits are paid.
B)the total amount a patient can be charged during a year.
C)the total dollar amount an insurance company will pay during the year.
D)the total dollar amount the insurance plan pays during the patient's lifetime.

Question 15

Of the following dental plans,which limits patients to a predetermined list of dentists?

A)Managed Care Plan
B)EPO Plan
C)HMO Plan
D)All of the above

Question 16

A teenager is new to the dental office and is filling out the new patient paperwork.When he gets to the insurance section,he asks you what he should put for subscriber.You explain that:

A)he is the subscriber.
B)his father is the subscriber.
C)his mother is the subscriber.
D)the holder of the dental benefits is the subscriber.

Question 17

Overbilling can be described as all of the following,except:

A)the dentist recommends and performs and charges for unnecessary dental services.
B)waiver of copayment,with third party payment accepted as full.
C)the dentist increases the fee solely because the patient has insurance.
D)fraudulent insurance billing.

Question 18

A patient is in need of an expensive dental procedure.He tells you that although it would be covered at 80% now,in 1 month,it will be covered at 90% when the new benefit year begins.You know that his insurance has:

A)a fixed fee schedule.
B)an incentive program.
C)a capitation program.
D)direct reimbursement.

Question 19

Fill in the blank: After _______ days,review and track any unpaid dental claims.

A)7
B)10
C)30
D)60

Question 20

The first step in processing a dental claim form is to discuss the insurance coverage with the patient,and determine the patient's portion.
.

Question 21

Once submitted,a paper dental claim has a turnaround time of approximately _______,while an electronically submitted claim has a turnaround of _______.

A)1 week,1 to 2 days
B)1 to 2 days,1 week
C)1 month,7 to 10 days
D)7 to 10 days,1 month

Question 23

Insurance companies calculate eligibility on a(n)_______ basis.

A)daily
B)weekly
C)monthly
D)annual

Question 24

How many data items must be entered to complete the ADA Dental Claim Form?

Question 25

Which of the following can aid the patient in billing the insurance company directly?

A)A superbill
B)An encounter form
C)An EOB form
D)A dental claim form