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.
