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 Denial Management and Appeals flashcards as text
A claim is denied with reason code CO-4. What does this denial indicate?
Answer: The procedure code is inconsistent with the modifier
CO-4 indicates the service was denied because the procedure code is inconsistent with the modifier used on the claim.
Which of the following best describes a 'soft denial' in revenue cycle management?
Answer: A denial that can be resolved by submitting additional information or correcting the claim
A soft denial is a temporary denial that can be overturned by providing missing information, correcting errors, or submitting supporting documentation.
When a payer denies a claim stating 'services not medically necessary,' what is the most critical document to include in an appeal?
Answer: A letter of medical necessity from the treating physician
A letter of medical necessity from the treating physician is the primary document needed to justify that the services were clinically appropriate.
A hospital receives a denial for an inpatient stay coded as DRG 470 (Major Joint Replacement). The payer argues the patient did not meet criteria for inpatient admission. Which appeal strategy is most appropriate?
Answer: Submit clinical documentation supporting the inpatient level of care decision
Submitting clinical documentation that supports the inpatient admission criteria is the appropriate first step in appealing a medical necessity denial for an inpatient stay.
Which federal regulation governs the external appeal process for patients enrolled in employer-sponsored health plans?
Answer: ERISA (Employee Retirement Income Security Act)
ERISA governs the claims and appeals process for most employer-sponsored group health plans, including the right to an external appeal.
What is the purpose of an Advance Beneficiary Notice (ABN) in the context of denial management?
Answer: It informs the patient that Medicare may not cover the service and obtains consent to bill the patient
An ABN notifies the patient that Medicare may deny coverage for a specific service and obtains the patient's agreement to be responsible for payment if Medicare denies it.
A claim denial states CO-97: 'The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.' What is the most likely cause?
Answer: A bundling edit has combined the denied service into another previously paid service
CO-97 typically results from NCCI (National Correct Coding Initiative) bundling edits that include the denied service within a previously paid, more comprehensive code.