CRCR - Certified Revenue Cycle Representative Program Denial Management and Appeals Flashcards

What is the primary purpose of a Peer-to-Peer (P2P) review in the denial management process?

Answer: To allow the treating physician to discuss the clinical case directly with the payer's medical reviewer

A P2P review gives the treating physician the opportunity to present clinical rationale directly to the payer's physician reviewer, often reversing medical necessity denials before a formal appeal.

A claim denied for 'lack of prior authorization' is later discovered to have had authorization obtained but the wrong auth number was entered. What is the best resolution path?

Answer: File an appeal with proof of the valid authorization number and confirmation from the payer

Submitting an appeal that includes documented proof of the valid prior authorization demonstrates that authorization was secured and the denial was due to a data entry error.

Which metric best measures the effectiveness of a denial prevention program over time?

Answer: Denial rate as a percentage of claims submitted

Tracking denial rate as a percentage of total claims submitted provides a normalized, trend-able measure of how well prevention efforts are reducing initial denials.

An appeal letter for a medical necessity denial should always include which of the following?

Answer: Patient-specific clinical documentation supporting the necessity of the service

Patient-specific clinical documentation—such as progress notes, lab results, and physician orders—directly addresses the payer's medical necessity criteria and is the foundation of a strong appeal.

When a payer denies a claim as 'out of network' but the provider holds a valid contract, what is the first step in the resolution process?

Answer: Verify the credentialing and contract effective dates with the payer's provider relations department

Contacting provider relations to confirm that the provider's credentialing is active and the contract dates are correctly loaded addresses the root cause of most erroneous out-of-network denials.

A hospital's denial management dashboard shows a spike in 'bundling' denials for cardiac catheterization cases. What is the most likely root cause?

Answer: Component billing of procedures that are included in the global catheterization code

Bundling denials for cardiac catheterization typically result from billing ancillary components such as radiological supervision separately when they are already included in the comprehensive procedure code.

Under ERISA, a self-funded plan must provide a written notice of benefit denial within how many days for a non-urgent post-service claim?

Answer: 60 days

ERISA regulations require ERISA-governed plans to furnish a written denial notice for post-service claims within 60 days of receiving the claim.