CBCS - Certified Billing and Coding Specialist Denial Management and Appeals Questions and Answers

Question 1

A claim submitted to Medicare is denied. According to the standard Medicare Part A and B appeals process, what is the first level of appeal that a provider's office must initiate?

Accepted Answer

Redetermination by the Medicare Administrative Contractor (MAC)

Answer

Reconsideration by a Qualified Independent Contractor (QIC)

Answer

Hearing by an Administrative Law Judge (ALJ)

Answer

Review by the Medicare Appeals Council

Question 2

A billing specialist receives an explanation of benefits (EOB) with a denial code CO-16. This indicates the 'Claim/service lacks information which is needed for adjudication.' The data on the submitted claim form itself appears to be complete. Which of the following is the MOST likely reason for this denial?

Accepted Answer

The payer required supporting documentation, like a prior authorization number or medical records, which was not sent with the claim.

Answer

The service was performed on a date the patient's policy was not active.

Answer

The diagnosis code does not support medical necessity for the procedure.

Answer

The claim was submitted after the payer's timely filing limit.

Question 3

A practice's billing manager is analyzing denial trends to identify areas for improvement. Which of the following denial reasons points to a preventable error that should be addressed by front-desk staff during patient registration and check-in?

Accepted Answer

Patient's insurance coverage was terminated prior to the date of service.

Answer

Service not covered under the patient's benefit plan.

Answer

Claim denied for exceeding the timely filing limit.

Answer

Procedure determined to be not medically necessary.

Question 4

A claim for a new, innovative surgical procedure is denied by a commercial payer as 'experimental and investigational.' The surgeon believes the procedure was medically necessary and has peer-reviewed medical journals to support its use. What is the most appropriate next step?

Accepted Answer

File a formal appeal that includes a letter of medical necessity and copies of the supporting journal articles.

Answer

Write off the balance as a contractual loss.

Answer

Immediately send the patient a bill for the full amount of the service.

Answer

Resubmit the claim with a different, more common procedure code.

Question 5

A medical office receives a denial stating the claim was not filed within the payer's required timeframe. The billing specialist investigates and confirms the claim was sent electronically 60 days before the deadline and has a clearinghouse acceptance report as proof. What is the best course of action?

Accepted Answer

File a timely filing appeal with the payer, including a copy of the clearinghouse acceptance report as proof of submission.

Answer

Bill the patient for the full amount, as the insurance has refused to pay.

Answer

Submit a corrected claim with a new date of service.

Answer

Accept the denial and write off the balance to bad debt.

Question 6

Which of the following BEST describes the primary purpose of a well-written appeal letter for a denied claim?

Accepted Answer

To present a clear, factual, and evidence-based argument explaining why the original decision should be overturned.

Answer

To establish a formal record of disagreement for future legal action.

Answer

To request a comprehensive list of the patient's covered benefits and exclusions from the payer.

Answer

To notify the patient that they will be responsible for the full balance if the appeal is unsuccessful.

A claim submitted to Medicare is denied.According to the standard Medicare Part A and B appeals process, what is the first level of appeal that a provider's office must initiate?

A claim submitted to Medicare is denied.
According to the standard Medicare Part A and B appeals process, what is the first level of appeal that a provider's office must initiate?