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 returned to the provider as unprocessable. What is the most likely reason for this status?
Answer: Missing or invalid required data elements on the claim form
Claims returned as unprocessable typically lack required data elements or contain invalid information that prevents adjudication.
Which remittance advice code category indicates that a claim or service line was denied?
Answer: CO (Contractual Obligation)
CO (Contractual Obligation) codes indicate amounts the provider has contractually agreed not to bill the patient, including denials under contract.
What does the term 'coordination of benefits' (COB) refer to in claims adjudication?
Answer: The process of determining which payer pays first when a patient has multiple insurers
COB is the process insurers use to determine the order of payment responsibility when a patient has more than one insurance plan.
A Medicare Advantage plan denies a claim stating the service required prior authorization that was not obtained. Which action should the biller take first?
Answer: Review whether prior authorization was actually required and appeal if appropriate
The biller should verify whether prior authorization was truly required for the service before deciding to appeal or accept the denial.
On an 837P electronic claim, which loop contains the subscriber's information?
Answer: Loop 2010BA
Loop 2010BA in the 837P transaction contains the subscriber (insured) name and demographic information.
Which of the following best describes a 'split claim'?
Answer: A single episode of care billed across multiple claims due to payer rules or date spans
A split claim divides services from one episode of care into separate claims, often required when services span a payer's billing period limit.
What is the purpose of a claim attachment in the adjudication process?
Answer: To provide supporting documentation that justifies the billed service
Claim attachments provide additional clinical or administrative documentation to support medical necessity or clarify billed services.