Claims Processing and Billing Flashcards
7 cards from real CRCR practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Claims Processing and Billing flashcards as text
A provider submits a claim with a diagnosis code that is not specific enough (missing required characters). How will most payers respond?
Answer: Deny or reject the claim for invalid diagnosis code
Payers will deny or reject claims with incomplete ICD-10-CM codes because codes must be reported to the highest level of specificity available.
What is the significance of the 'place of service' (POS) code on a CMS-1500 claim form?
Answer: It indicates the setting where the service was rendered and affects reimbursement rates
The POS code identifies the setting where the service was performed, and payers use it to determine the appropriate reimbursement rate.
A claim is denied for 'timely filing.' The provider has documentation that the claim was submitted within the timely filing period. What should the provider do?
Answer: Appeal the denial with proof of timely submission such as a clearinghouse confirmation
The provider should appeal with documented proof of timely submission, such as a clearinghouse batch confirmation report with a timestamp.
Which type of edit checks for duplicate claim submissions within a payer's system?
Answer: Duplicate claim edit
Duplicate claim edits identify when an identical or substantially similar claim has already been submitted and paid for the same patient, service, and date.
When billing Medicare for an outpatient hospital service, what payment system is used?
Answer: Ambulatory Payment Classifications (APC)
Medicare uses Ambulatory Payment Classifications (APCs) under the Outpatient Prospective Payment System (OPPS) for outpatient hospital services.
A payer requests additional information to process a claim, sending a 'development letter.' What is the provider's best course of action?
Answer: Respond with the requested documentation within the payer's specified timeframe
The provider must respond promptly with the requested documentation within the payer's timeframe or risk denial of the claim.
What does the term 'fee schedule' mean in healthcare billing?
Answer: A predetermined list of maximum allowable amounts a payer will reimburse for specific services
A fee schedule is a payer's predetermined list of maximum allowable reimbursement amounts for specific procedures and services.