Denial Management & Appeals 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 Denial Management & Appeals flashcards as text
What is the purpose of an Explanation of Benefits (EOB) in the denial management process?
Answer: It details payer decisions including payment amounts, adjustments, and denial reasons
An EOB is sent to the patient and details how their insurance claim was processed, including payments, contractual adjustments, patient responsibility, and denial reasons.
Which type of appeal is submitted directly to an independent external reviewer when internal payer appeals are exhausted?
Answer: External appeal
An external appeal is reviewed by an independent organization outside the insurance company and is typically the last step when internal appeals are denied.
A denial is received with remark code N130. What does this indicate?
Answer: Payment is issued based on a lesser of cost provision
Remark code N130 indicates the payment was made using a lesser-of-cost provision, meaning the payer paid the lower of the billed amount or allowable rate.
When building an appeal letter for a denied claim, which element is MOST critical to include?
Answer: A clear reference to the denied claim, clinical justification, and relevant policy language
An effective appeal letter must reference the specific denied claim, provide clinical or policy-based justification, and cite relevant payer policy language to support the reversal.
What does a denial with reason code PR-1 indicate?
Answer: Deductible amount applied — patient responsibility
PR-1 is a Patient Responsibility adjustment reason code indicating that the amount was applied to the patient's deductible.
Which federal law gives patients the right to appeal health insurance claim denials?
Answer: ERISA and the ACA
Both ERISA (for employer-sponsored plans) and the ACA (for marketplace and non-grandfathered plans) provide patients with the right to internal and external appeals of denied claims.
A biller receives a denial for 'missing or invalid modifier.' What is the correct course of action?
Answer: Review the procedure code, determine the correct modifier, and resubmit a corrected claim
When a claim is denied for a missing or invalid modifier, the biller should verify which modifier is appropriate for that procedure and payer, then resubmit a corrected claim.