AAPC Claims Management & Adjudication 2 — Questions and Answers
Question 1: A claim is returned to the provider as unprocessable. What is the most likely reason for this status?
- The patient's deductible has not been met
- Missing or invalid required data elements on the claim form (Correct answer)
- The service was not medically necessary
- The provider is out-of-network
Correct 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.
Question 2: Which remittance advice code category indicates that a claim or service line was denied?
- CO (Contractual Obligation) (Correct answer)
- PR (Patient Responsibility)
- OA (Other Adjustment)
- CR (Correction and Reversal)
Correct answer: CO (Contractual Obligation)
CO (Contractual Obligation) codes indicate amounts the provider has contractually agreed not to bill the patient, including denials under contract.
Question 3: What does the term 'coordination of benefits' (COB) refer to in claims adjudication?
- Billing the patient for any remaining balance after insurance pays
- The process of determining which payer pays first when a patient has multiple insurers (Correct answer)
- Submitting corrected claims to a secondary payer
- Verifying patient eligibility before rendering services
Correct 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.
Question 4: A Medicare Advantage plan denies a claim stating the service required prior authorization that was not obtained. Which action should the biller take first?
- Write off the balance as a contractual adjustment
- File a claim with secondary insurance immediately
- Review whether prior authorization was actually required and appeal if appropriate (Correct answer)
- Rebill the claim with a different procedure code
Correct 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.
Question 5: On an 837P electronic claim, which loop contains the subscriber's information?
- Loop 2000A
- Loop 2010BA (Correct answer)
- Loop 2300
- Loop 2400
Correct answer: Loop 2010BA
Loop 2010BA in the 837P transaction contains the subscriber (insured) name and demographic information.
Question 6: Which of the following best describes a 'split claim'?
- A claim submitted with both professional and facility charges
- A single episode of care billed across multiple claims due to payer rules or date spans (Correct answer)
- A claim denied and resubmitted with corrections
- A claim shared between two providers for the same service
Correct 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.
Question 7: What is the purpose of a claim attachment in the adjudication process?
- To reduce the claim amount owed by the patient
- To provide supporting documentation that justifies the billed service (Correct answer)
- To notify the payer of a provider address change
- To request a fee schedule update from the payer
Correct 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.
AAPC Claims Management & Adjudication 2
A claim is returned to the provider as unprocessable.
What is the most likely reason for this status?