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
What is the purpose of the Medicare Secondary Payer (MSP) questionnaire?
Answer: To identify whether Medicare should be primary or secondary payer for a patient's services
The MSP questionnaire determines whether another insurer has primary payment responsibility before Medicare, which is mandated by law.
Which claim status code on a 277 transaction indicates the claim was accepted for adjudication?
Answer: A2 – Acknowledgement/Acceptance into adjudication system
A2 on a 277 transaction confirms the claim was accepted into the payer's adjudication system for processing.
A provider submits a claim with modifier -59. What does this modifier communicate to the payer?
Answer: The procedure represents a distinct service not normally reported with the other code on that date
Modifier -59 indicates the procedure is a distinct service, helping override bundling edits when services that are normally bundled are appropriately billed separately.
What is a Remittance Advice (RA) used for by the billing department?
Answer: To reconcile payments received with claims submitted and identify underpayments or denials
The RA (or EOB) is used to post payments, identify denied or adjusted claims, and reconcile accounts receivable.
Which of the following is a valid reason a payer may apply a 'global period' payment limitation?
Answer: Post-operative services are considered included in the surgical fee for a set number of days
Global surgery packages include pre-operative, intraoperative, and post-operative care within a defined period, so routine follow-up visits are not separately reimbursable.
When a claim is adjusted after initial payment and the payer recoups funds, what document typically accompanies this action?
Answer: An adjusted or voided Remittance Advice with the recoupment details
Payers issue an adjusted RA or reversal notice showing the original payment, the recoupment amount, and the reason for the adjustment.
A claim for a hospital outpatient service is denied because the patient's plan requires services be rendered at an in-network facility. Under what category does this denial fall?
Answer: Network/eligibility denial
Denials based on the facility not being in the patient's network are classified as network or eligibility-related denials.