CRCR - Certified Revenue Cycle Representative Program Denial Management and Appeals 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 CRCR - Certified Revenue Cycle Representative Program Denial Management and Appeals flashcards as text
A claim is denied because the procedure code is inconsistent with the patient's age. What type of denial is this?
Answer: Clinical edit denial
A clinical edit denial occurs when the billed procedure or diagnosis conflicts with patient demographics such as age or gender.
Which document should a provider request first when a payer denies a claim citing 'not medically necessary'?
Answer: The payer's clinical coverage policy or LCD
Reviewing the payer's clinical coverage policy or Local Coverage Determination (LCD) identifies the criteria the payer uses to define medical necessity for that service.
A payer issues a denial with CARC 16 and RARC N56. What action should the biller take?
Answer: Correct the claim information and resubmit as a corrected claim
CARC 16 indicates the claim contains missing or invalid information; RARC N56 points to a specific data element that must be corrected before the claim can be processed.
Under the ACA, what is the maximum number of levels of internal appeals an insurer can require a member to exhaust before accessing external review?
Answer: One
The ACA limits insurers to requiring no more than one level of internal appeal before a member may request an independent external review.
A hospital receives a denial for a 3-day inpatient stay stating the admission was not medically necessary but the services rendered were. What is the most appropriate appeal strategy?
Answer: Appeal using InterQual or Milliman criteria supporting the inpatient level of care
Submitting clinical criteria such as InterQual or Milliman evidence in the appeal demonstrates that the inpatient level of care met nationally recognized standards.
Which federal regulation requires Medicare Advantage plans to provide enrollees with a standardized notice of denial and appeal rights?
Answer: CMS Medicare Managed Care Manual Chapter 13
CMS Medicare Managed Care Manual Chapter 13 governs Medicare Advantage organization determinations, appeals, and grievances, including required denial notice language.
A provider submits a claim for a bilateral procedure using modifier 50. The payer denies one unit as a duplicate. What is the correct corrective action?
Answer: Appeal the denial and include documentation explaining bilateral coding guidelines
Appealing with an explanation of bilateral procedure coding rules and clinical documentation showing both sides were treated supports payment for the correctly billed bilateral service.