PSI Ohio Insurance Practice Exam

When will a dental policy typically pay on a UCR basis?

1. When emergency procedures are performed

2. When services are covered but not listed on a payment schedule

3. When the patient is a minor

4. When a pre-authorization is not obtained

The correct answer is: When services are covered but not listed on a payment schedule

A dental policy typically pays on a Usual, Customary, and Reasonable (UCR) basis when services are covered but not listed on a payment schedule. This situation often arises for dental treatments or procedures that do not have predetermined fees established within the insurance plan's coverage schedule. The UCR payment method ensures that the insurance company compensates the provider based on the standard fees charged for similar services by other dental practitioners in the same geographic area. This can help calculate a fair payment amount for both the dentist and the patient, particularly when the service provided is less common or not explicitly enumerated in the policy's coverage listing. In contrast, emergency procedures or the status of the patient (e.g., being a minor) do not inherently dictate a UCR payment model. Additionally, the need for pre-authorization is often separate from how payment is calculated. If pre-authorization is not obtained, this may impact the approval of payment rather than the basis of the payment calculations themselves. Understanding this concept is essential for navigating dental insurance claims and ensuring that patients and providers are appropriately compensated for services rendered.