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 role of patient access staff in preventing authorization-related denials?
Answer: To obtain required prior authorizations from payers before scheduled services are rendered
Patient access staff are responsible for identifying services that require prior authorization and securing payer approval before the patient receives care to prevent downstream denials.
Which claim form is most commonly used to bill professional (physician) services to Medicare and most other payers?
Answer: CMS-1500
The CMS-1500 form is the standard paper claim form used by physicians, non-institutional providers, and suppliers to bill Medicare, Medicaid, and most commercial insurers.
Which claim form is used to bill inpatient hospital and institutional outpatient services?
Answer: UB-04 (CMS-1450)
The UB-04 (also known as CMS-1450) is the standard institutional claim form used by hospitals, skilled nursing facilities, and other institutional providers to bill for services.
What is the National Provider Identifier (NPI) and why is it required on claims?
Answer: A unique 10-digit identification number assigned to healthcare providers, required on all HIPAA-covered claim transactions
The NPI is a standard unique identifier for healthcare providers under HIPAA, and its inclusion on claims is mandatory for processing by all covered payers.
What action should patient access staff take when a payer requests additional documentation to process a claim?
Answer: Promptly gather and submit the requested documentation within the payer's specified timeframe
Timely response to payer documentation requests is critical; failing to respond within the required timeframe can result in a hard denial and lost revenue.
What does the term 'medical necessity denial' mean?
Answer: A denial issued when the payer determines the service was not medically necessary based on clinical criteria
Medical necessity denials occur when the payer concludes that the service does not meet established clinical criteria for coverage, often requiring clinical documentation or an appeal to overturn.