Certified Risk Adjustment Coder (CRC)

Which type of health claims are generally NOT used in predictive modeling for chronic conditions?

1. Rx claims

2. Inpatient claims

3. DME claims

4. Dental claims

The correct answer is: Dental claims

Dental claims are generally not used in predictive modeling for chronic conditions because they primarily pertain to oral health care rather than systemic health issues. Predictive modeling aims to forecast the likelihood of health outcomes based on a range of medical data pertinent to chronic diseases. Dental claims usually cover services related to the prevention, diagnosis, and treatment of dental-related issues, which are considered separate from the management of chronic conditions such as diabetes, heart disease, or respiratory disorders. In contrast, Rx claims provide information about medication usage, inpatient claims include hospital admissions that are critical for assessing the severity of chronic conditions, and DME claims—related to durable medical equipment—offer insights into the ongoing care needs of patients with chronic illnesses. These three types of claims are much more relevant in understanding and predicting the course of chronic conditions, making dental claims the least applicable in this context.