CHAA CHAA Denial Management and Claims Processing 2 — Questions and Answers
Question 1: What is the purpose of an appeal in the claims denial process?
- To waive the patient's copay
- To formally contest a payer's denial decision and request reconsideration or overturn (Correct answer)
- To change the patient's insurance plan
- To resubmit a clean claim without any changes
Correct 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.
Question 2: Which of the following is the most common front-end cause of claim denials?
- Incorrect surgical technique
- Missing or invalid prior authorization (Correct answer)
- Physician documentation errors
- Laboratory test failures
Correct 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.
Question 3: What is a Remittance Advice (RA) or Explanation of Benefits (EOB)?
- A document sent to patients explaining their insurance deductible
- A document from the payer explaining how a claim was processed, what was paid, and why any portion was denied or adjusted (Correct answer)
- A pre-authorization approval letter
- A charge description master listing service prices
Correct 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.
Question 4: What does 'coordination of benefits' (COB) mean and why is it important?
- The process of scheduling multiple providers for one visit
- The process that determines which of a patient's multiple insurance plans pays first (primary) and which pays second (secondary) (Correct answer)
- A billing method for outpatient services
- A payer contract negotiation process
Correct 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.
Question 5: What information is required on a clean claim to avoid processing delays?
- Only the patient's name and date of birth
- Complete and accurate patient demographics, insurance information, diagnosis codes, procedure codes, NPI, and dates of service (Correct answer)
- Just the procedure code and billed amount
- Only the provider's tax ID and NPI
Correct 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.
Question 6: What is a write-off in the context of claims adjudication?
- The amount billed above the Medicare fee schedule that must be written off per contract (Correct answer)
- Money collected from the patient at time of service
- The insurance premium paid by the employer
- A penalty charged to providers for late filing
Correct 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.
CHAA CHAA Denial Management and Claims Processing 2
What is the purpose of an appeal in the claims denial process?