AAPC Claims Management & Adjudication 2

Question 1

A claim is returned to the provider as unprocessable. What is the most likely reason for this status?

Accepted Answer

Missing or invalid required data elements on the claim form

Answer

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?

Accepted Answer

CO (Contractual Obligation)

Answer

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?

Accepted Answer

The process of determining which payer pays first when a patient has multiple insurers

Answer

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?

Accepted Answer

Review whether prior authorization was actually required and appeal if appropriate

Answer

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?

Accepted Answer

Loop 2010BA

Answer

Loop 2010BA in the 837P transaction contains the subscriber (insured) name and demographic information.

(AAPC) American Academy of Professional Coders Biller Certified Practice Test

(AAPC) American Academy of Professional Coders Biller Certified Practice Test

AAPC Claims Management & Adjudication 2