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
Under Medicare's claim appeal process, which level allows for a hearing before an Administrative Law Judge (ALJ)?
Answer: Level 3 – ALJ Hearing
Level 3 of the Medicare appeals process is a hearing before an Administrative Law Judge, available when the disputed amount meets the minimum threshold.
A claim is denied because the referring physician's NPI is missing from the claim form. On which box of the CMS-1500 form should the referring provider's NPI appear?
Answer: Box 17b
The referring provider's NPI is entered in Box 17b of the CMS-1500 claim form.
What does 'exhaustion of internal remedies' mean in the context of health plan appeals?
Answer: The claimant has completed all required internal appeal levels before seeking external review
Exhaustion of internal remedies means the claimant has pursued and completed all levels of internal appeals required by the plan before they are eligible to request an external independent review.
Which of the following best describes the role of a Recovery Audit Contractor (RAC) in the context of denial management?
Answer: They identify and recover improper payments made by Medicare through post-payment audits
RACs are CMS-contracted auditors that review paid Medicare claims to identify and recover overpayments made due to billing errors or medical necessity issues.
A payer denies a claim citing a lack of prior authorization. The provider has documented proof that authorization was obtained verbally. What is the best next step?
Answer: Append the verbal authorization reference number and date to the appeal and request reconsideration
Documenting the verbal authorization with the reference number, date, and representative name in an appeal letter is the appropriate first step to reverse an authorization-related denial.
What is the primary purpose of tracking a denial's 'root cause' in a denial management program?
Answer: To identify process failures upstream so that preventive measures can be implemented
Root cause analysis in denial management identifies systemic process failures—such as registration errors or coding gaps—so that preventive actions can reduce future denial rates.
Which metric is used to measure the percentage of total claims that are denied by payers within a given period?
Answer: Denial Rate
The denial rate measures the proportion of submitted claims that are denied by payers and is a key performance indicator in denial management.