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 provider files a timely appeal but the payer does not respond within the contracted turnaround time. What is the appropriate action?
Answer: Document the non-response and escalate to the payer's provider relations department or file a complaint with the state insurance regulator
When a payer fails to respond within the contracted or regulatory timeframe, escalating through provider relations and filing a regulatory complaint are the appropriate remedies.
Under ERISA, what is the maximum timeframe a plan has to respond to a standard (non-urgent) benefit claim appeal?
Answer: 60 days
ERISA regulations require group health plans to respond to standard internal appeals within 60 days of receiving the appeal.
Which of the following is an example of a 'clinical edit' denial?
Answer: A claim denied because the diagnosis code does not support the medical necessity of the procedure billed
A clinical edit denial occurs when the diagnosis code(s) on the claim do not meet the payer's criteria to justify the medical necessity of the procedure performed.
In managing Medicaid claim denials, which state-specific tool is most important for understanding covered services and billing policies?
Answer: The state Medicaid fee schedule and provider manual
Each state's Medicaid program is governed by its own provider manual and fee schedule, which outline covered services, billing requirements, and appeal procedures.
What is the significance of the 'write-off rate' as a denial management KPI?
Answer: It represents the percentage of denied claim value that is ultimately uncollected and written off
The write-off rate reflects the proportion of denied claim dollars that are never recovered, indicating the financial impact of denials that cannot be successfully appealed or corrected.
A Medicare claim is denied because the National Coverage Determination (NCD) does not cover the service for the billed diagnosis. Which of the following is the most appropriate appeal strategy?
Answer: Request a waiver of liability and bill the patient if an ABN was signed
If an ABN was signed and Medicare's NCD excludes coverage for that diagnosis, the provider may shift liability to the patient and collect through a waiver of liability process.
Which of the following best describes 'concurrent review' in the utilization management context that can affect denial rates?
Answer: An ongoing payer review of a patient's continued inpatient stay to authorize additional days
Concurrent review is the real-time payer evaluation of an inpatient stay's medical necessity, and failure to participate can result in denial of additional inpatient days.