CHAA Denial Management and Claims Processing Flashcards
6 cards from real CHAA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 CHAA Denial Management and Claims Processing flashcards as text
What is the purpose of an appeal in the claims denial process?
Answer: To formally contest a payer's denial decision and request reconsideration or overturn
An appeal is a formal request to the payer to review and reconsider a denial decision, often supported by clinical documentation, coding corrections, or authorization records.
Which of the following is the most common front-end cause of claim denials?
Answer: Missing or invalid prior authorization
Missing or invalid prior authorizations are one of the leading front-end denial causes, directly tied to patient access staff failing to obtain required approvals before service.
What is a Remittance Advice (RA) or Explanation of Benefits (EOB)?
Answer: A document from the payer explaining how a claim was processed, what was paid, and why any portion was denied or adjusted
An RA/EOB is the payer's response to a submitted claim that details payment amounts, contractual adjustments, and denial reasons for each billed service.
What does 'coordination of benefits' (COB) mean and why is it important?
Answer: The process that determines which of a patient's multiple insurance plans pays first (primary) and which pays second (secondary)
COB rules establish primary and secondary payer order when a patient has multiple plans, preventing duplicate payments and ensuring accurate billing to each payer.
What information is required on a clean claim to avoid processing delays?
Answer: Complete and accurate patient demographics, insurance information, diagnosis codes, procedure codes, NPI, and dates of service
A clean claim includes all required fields—demographics, payer info, accurate ICD and CPT codes, provider identifiers, and service dates—so the payer can adjudicate without requesting additional information.
What is a write-off in the context of claims adjudication?
Answer: The amount billed above the Medicare fee schedule that must be written off per contract
Contractual write-offs (adjustments) represent the difference between the provider's billed charges and the payer's allowed amount per the negotiated contract, which cannot be billed to the patient.