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

A payer consistently denies claims for a specific high-cost drug citing 'experimental or investigational.' The drug has FDA approval. What is the strongest appeal argument?

Answer: The drug has received full FDA approval and meets evidence-based clinical guidelines for the diagnosis

FDA approval combined with evidence-based guideline support directly refutes an experimental/investigational denial, as approved drugs used on-label cannot be classified as experimental.

Which type of denial requires the provider to obtain a signed Advance Beneficiary Notice (ABN) from the patient before billing the patient for the non-covered service?

Answer: Medicare medical necessity denial when the provider believes Medicare will deny

An ABN must be issued when a provider believes Medicare is likely to deny a service as not medically necessary, allowing the provider to hold the patient liable for the charge if Medicare denies.

A revenue cycle team notices that 40% of authorization-related denials are for procedures performed on weekends. What process improvement would best address this pattern?

Answer: Implement a weekend authorization verification workflow or on-call authorization team

A dedicated weekend authorization workflow ensures that prior authorizations are verified and obtained even when standard business office staff are unavailable.

What is the role of a 'denial reason code crosswalk' in a denial management program?

Answer: It maps payer-specific denial codes to standardized CARC/RARC codes to facilitate root-cause analysis

A denial reason code crosswalk standardizes payer-specific denial language to CARC/RARC codes, enabling consistent trend analysis across multiple payers.

When calculating the 'cost to collect' on a denied claim, which factor should be weighed against the expected reimbursement to determine whether to pursue an appeal?

Answer: Staff time, appeal fees, and administrative resources required to work the denial

Weighing appeal costs—staff time, documentation retrieval, and submission effort—against the expected payment helps prioritize which denials are financially worth pursuing.

A claim for a surgical procedure is denied because the assistant surgeon's services are not covered per the patient's benefit plan. Which action is appropriate?

Answer: Inform the patient of the non-covered benefit and determine if a patient financial responsibility policy applies

When assistant surgeon benefits are excluded from the patient's plan, notifying the patient and reviewing the financial responsibility policy is appropriate before determining the correct billing action.

Which of the following best describes the concept of 'global days' in the context of denial management for surgical claims?

Answer: A post-operative period during which follow-up services are included in the surgical procedure payment and billed separately will be denied

Global days define the post-operative period (0, 10, or 90 days) during which routine follow-up care is bundled into the surgical payment and cannot be billed separately without a modifier.