CRCR CRCR - Certified Revenue Cycle Representative Program Denial Management and Appeals 2

Question 1

What is the difference between a claim rejection and a claim denial?

Accepted Answer

A rejection means the claim was not processed due to errors; a denial means the claim was processed but payment was refused

Answer

Rejections occur at the front end due to formatting or data errors; denials occur after adjudication when a processed claim is not paid.

Question 2

Which denial reason code typically indicates that a required prior authorization was not obtained?

Accepted Answer

CO-15 payment adjusted because the authorization number is missing invalid or does not apply

Answer

CO-15 indicates an authorization number issue, which is the standard denial for missing or invalid prior authorization.

Question 3

What is the purpose of maintaining a denial log in revenue cycle management?

Accepted Answer

To track denial trends, identify root causes, and measure the effectiveness of corrective actions

Answer

A denial log enables systematic tracking of denial patterns, which is essential for identifying root causes and measuring improvement initiatives.

Question 4

A payer denies a claim stating the procedure is not medically necessary. The provider disagrees. What is the most appropriate next step?

Accepted Answer

Submit a peer-to-peer review request or file a formal appeal with supporting clinical documentation

Answer

Medical necessity denials should be challenged with clinical documentation and when appropriate a peer-to-peer physician review.

Question 5

What does first-pass resolution rate measure in denial management?

Accepted Answer

The percentage of claims paid on the first submission without denial

Answer

First-pass resolution rate measures how many claims are paid without requiring rework, denials, or resubmission.

CRCR - Certified Revenue Cycle Representative Program Practice Test