Denial Management and Appeals Flashcards
6 cards from real CBCS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Denial Management and Appeals flashcards as text
What is a write-off in medical billing, and when is it appropriate?
Answer: A write-off is the adjustment of a balance that cannot or should not be collected — appropriate for contractual adjustments, small balance write-offs per policy, and hardship cases
Write-offs are appropriate for contractual adjustments (required by payer contracts), small balances (per practice policy), uncollectible accounts, and charity care — but should never be used to avoid collecting legitimate patient balances improperly.
What is a denial trend analysis and why is it important?
Answer: Identifying patterns in claim denials by reason code, payer, or service type to find and fix root causes of denials
Denial trend analysis involves tracking denials by type, payer, provider, and service to identify systemic issues. Finding root causes allows the practice to prevent denials proactively rather than just reacting to them.
What is an external appeal in the context of insurance claim denials?
Answer: An appeal reviewed by an independent organization outside the insurance company, available after exhausting internal appeals
An external appeal (independent external review) is conducted by an Independent Review Organization (IRO) outside the insurance company after the internal appeals process has been exhausted, providing an unbiased review.
What is claim scrubbing?
Answer: Automated review of claims for errors (coding, eligibility, missing data) before submission to reduce denials
Claim scrubbing is an automated pre-submission process that checks claims for coding errors, missing information, eligibility issues, and payer-specific rules to catch errors before the claim reaches the payer.
What is the significance of CARC (Claim Adjustment Reason Codes) on a remittance advice?
Answer: They are standardized codes that explain why a claim was adjusted or denied, used to categorize and manage denials effectively
CARCs are standardized codes maintained by the X12 organization that appear on ERAs/RAs to explain why a payment was adjusted or denied. They allow for systematic tracking and management of denials.
What is the purpose of an Advance Beneficiary Notice (ABN) in Medicare billing?
Answer: To inform a Medicare beneficiary that a service may not be covered by Medicare so they can decide whether to receive the service and accept financial responsibility
An ABN is a written notice given to a Medicare beneficiary before a service is provided when the provider believes Medicare may not cover the service, allowing the patient to make an informed financial decision.