CHAA CHAA Denial Management and Claims Processing 2

Question 1

What is the purpose of an appeal in the claims denial process?

Accepted Answer

To formally contest a payer's denial decision and request reconsideration or overturn

Answer

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?

Accepted Answer

Missing or invalid prior authorization

Answer

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)?

Accepted Answer

A document from the payer explaining how a claim was processed, what was paid, and why any portion was denied or adjusted

Answer

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?

Accepted Answer

The process that determines which of a patient's multiple insurance plans pays first (primary) and which pays second (secondary)

Answer

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?

Accepted Answer

Complete and accurate patient demographics, insurance information, diagnosis codes, procedure codes, NPI, and dates of service

Answer

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.

CHAA - Certified Healthcare Access Associate Practice Test

CHAA - Certified Healthcare Access Associate Practice Test

CHAA CHAA Denial Management and Claims Processing 2