AAPC Denial Management & Appeals

Question 1

Which denial reason code indicates that a claim was rejected because the service is not covered under the patient's plan?

Accepted Answer

CO-96

Answer

CO-96 is the CARC (Claim Adjustment Reason Code) used when a service is not covered under the patient's plan or benefit package.

Question 2

What is the first step a biller should take when a claim is denied due to 'coordination of benefits' (COB)?

Accepted Answer

Verify primary and secondary insurance information and resubmit in correct order

Answer

When a claim is denied for COB issues, the biller must verify which payer is primary and which is secondary, then resubmit claims in the correct order.

Question 3

A claim is denied with reason code CO-29. What does this mean?

Accepted Answer

The time limit for filing has expired

Answer

CO-29 indicates the claim was denied because it was filed after the payer's timely filing deadline.

Question 4

Which document is most important to include when appealing a claim denied for 'medical necessity'?

Accepted Answer

Physician's clinical documentation and supporting medical records

Answer

Medical necessity appeals require clinical documentation such as physician notes, test results, and treatment plans to justify that the service was medically necessary.

Question 5

What is a 'timely filing' denial, and what is the typical remedy?

Accepted Answer

A denial because the claim was submitted after the payer's deadline; remedy is providing proof of timely submission

Answer

Timely filing denials occur when claims are submitted past the payer's deadline; billers can appeal by providing proof (e.g., electronic submission reports) that the claim was sent within the allowed window.

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

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

AAPC Denial Management & Appeals