CBCS Denial Management and Appeals 2

Question 1

What is the first step a medical biller should take upon receiving a claim denial?

Accepted Answer

Identify the denial reason code and determine whether the denial is correctable, appealable, or valid

Answer

Upon receiving a denial, the first step is to review the reason/remark codes on the remittance advice to understand why the claim was denied and determine the appropriate course of action.

Question 2

What is the difference between a claim denial and a claim rejection in terms of next steps?

Accepted Answer

Denied claims require a formal appeal through the payer's process; rejected claims are corrected and resubmitted as a new claim

Answer

A rejected claim was never processed — correct the errors and resubmit as a new claim. A denied claim was processed and requires a formal appeal through the payer's established appeals process.

Question 3

What is a peer-to-peer review in the context of insurance denials?

Accepted Answer

A physician-to-physician discussion between the treating provider and the payer's medical reviewer to discuss a denied or potentially denied service

Answer

A peer-to-peer review involves direct physician communication between the treating provider and the insurance company's medical director to discuss medical necessity for a denied or precertification decision.

Question 4

What information should be included in a formal appeal letter for a denied claim?

Accepted Answer

Patient information, claim details, denial reason, clinical documentation supporting medical necessity, applicable policies/guidelines, and a specific request for reconsideration

Answer

A complete appeal letter includes patient and claim identification, the specific denial reason being appealed, supporting clinical documentation, references to clinical guidelines, and a clear request for the specific action sought.

Question 5

What is a corrected claim and when is it used?

Accepted Answer

A resubmission of a previously processed claim with corrections to errors, submitted with frequency code 7 (replacement) or 8 (void)

Answer

A corrected claim replaces a previously processed (paid, denied, or partially paid) claim to fix billing errors. It is identified with bill type frequency code 7 (replacement) or 8 (void/cancel) on institutional claims, or with condition code on professional claims.

(CBCS) Certified Billing and Coding Specialist Practice Test

(CBCS) Certified Billing and Coding Specialist Practice Test

CBCS Denial Management and Appeals 2