Claims Management & Adjudication Flashcards
7 cards from real AAPC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Claims Management & Adjudication flashcards as text
A claim is denied with reason code CO-4. What does this indicate?
Answer: The procedure code is inconsistent with the modifier or service billed
CO-4 means the procedure code is inconsistent with the modifier billed, requiring a correction before resubmission.
What is the standard timely filing limit for Medicare Part B claims?
Answer: 12 months from date of service
Medicare Part B requires claims to be filed within 12 months (one calendar year) from the date of service.
When should a provider submit a corrected claim rather than a new claim?
Answer: When the original claim was processed but contained errors requiring correction
A corrected claim is submitted when an original claim was processed (paid or denied) but contained billing errors that need to be fixed.
Which payer adjudication step involves checking whether a service is included in the patient's benefit plan?
Answer: Coverage determination
Coverage determination confirms whether the specific service billed is a covered benefit under the patient's health plan.
An insurer denies a claim citing 'duplicate submission.' The provider confirms only one claim was sent. What is the next best step?
Answer: Send a reconsideration request with proof that only one claim was submitted
The provider should appeal or submit a reconsideration with documentation showing the claim was not duplicated.
What is the role of the clearinghouse in electronic claim submission?
Answer: It translates and reformats claims into payer-specific formats and checks for errors before transmission
A clearinghouse acts as an intermediary that scrubs claims for errors and translates them into the format required by individual payers.
Under the birthday rule for COB with two commercial plans covering a dependent child, which parent's plan is primary?
Answer: The plan of the parent whose birthday falls earlier in the calendar year (month and day)
The birthday rule designates the parent whose birthday (month and day) falls earliest in the calendar year as the primary insurer for a dependent child.