CHAA CHAA Denial Management and Claims Processing 1 — Questions and Answers
Question 1: What is a claim denial in the context of healthcare revenue cycle?
- When a patient refuses treatment
- When a payer refuses to reimburse a submitted claim fully or partially (Correct answer)
- When a provider cancels an appointment
- When a patient's copay is waived
Correct answer: When a payer refuses to reimburse a submitted claim fully or partially
A claim denial occurs when a payer determines that all or part of a submitted claim does not meet requirements for reimbursement, requiring follow-up or appeal.
Question 2: Which type of denial can be corrected and resubmitted by the provider?
- Hard denial
- Soft denial (or correctable denial) (Correct answer)
- Final denial
- Contractual denial
Correct answer: Soft denial (or correctable denial)
A soft denial is one where the payer will reconsider and pay the claim if additional information, a correction, or documentation is submitted.
Question 3: What is a 'hard denial' in claims management?
- A denial that can be resolved with additional documentation
- A denial that is final and cannot be overturned without a formal appeal (Correct answer)
- A denial due to a missing authorization number
- A denial caused by incorrect patient demographics
Correct answer: A denial that is final and cannot be overturned without a formal appeal
A hard denial represents a final refusal to pay that requires a formal appeal process if the provider believes the denial is incorrect.
Question 4: Which denial root cause originates in the patient access department due to missing or incorrect information at registration?
- Clinical denial
- Front-end denial (Correct answer)
- Back-end denial
- Contractual adjustment
Correct answer: Front-end denial
Front-end denials are caused by errors or omissions in registration data such as incorrect demographics, missing insurance information, or absent authorizations.
Question 5: What does 'timely filing' mean in the context of claim submission?
- Submitting claims in alphabetical order
- Submitting claims to the payer within the contractually specified deadline after service (Correct answer)
- Filing annual tax returns for the hospital
- Completing pre-authorization before service
Correct answer: Submitting claims to the payer within the contractually specified deadline after service
Timely filing limits require claims to be submitted within a specified window (e.g., 90 or 180 days) after the date of service; claims submitted late are typically denied.
Question 6: A claim is denied due to 'duplicate billing.' What does this mean?
- The patient was billed twice for the same service within the same billing cycle (Correct answer)
- The claim contained incorrect diagnosis codes
- The provider was not in-network
- The service was not medically necessary
Correct answer: The patient was billed twice for the same service within the same billing cycle
Duplicate billing occurs when the same service is submitted to a payer more than once, resulting in a denial on the second submission.
CHAA CHAA Denial Management and Claims Processing 1
What is a claim denial in the context of healthcare revenue cycle?