AAPC Denial Management & Appeals 2

Question 1

What is the purpose of an Explanation of Benefits (EOB) in the denial management process?

Accepted Answer

It details payer decisions including payment amounts, adjustments, and denial reasons

Answer

An EOB is sent to the patient and details how their insurance claim was processed, including payments, contractual adjustments, patient responsibility, and denial reasons.

Question 2

Which type of appeal is submitted directly to an independent external reviewer when internal payer appeals are exhausted?

Accepted Answer

External appeal

Answer

An external appeal is reviewed by an independent organization outside the insurance company and is typically the last step when internal appeals are denied.

Question 3

A denial is received with remark code N130. What does this indicate?

Accepted Answer

Payment is issued based on a lesser of cost provision

Answer

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.

Question 4

When building an appeal letter for a denied claim, which element is MOST critical to include?

Accepted Answer

A clear reference to the denied claim, clinical justification, and relevant policy language

Answer

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.

Question 5

What does a denial with reason code PR-1 indicate?

Accepted Answer

Deductible amount applied — patient responsibility

Answer

PR-1 is a Patient Responsibility adjustment reason code indicating that the amount was applied to the patient's deductible.

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

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

AAPC Denial Management & Appeals 2