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
Which of the following is considered a 'hard denial' in denial management?
Answer: A denial for services rendered after the patient's coverage termination date
A hard denial for services rendered after coverage termination is generally not reversible because the patient had no active insurance on the date of service.
During the appeal process, what is a 'peer-to-peer review'?
Answer: A physician-to-physician conversation between the treating provider and the payer's medical reviewer to discuss a denied claim
A peer-to-peer review is a direct conversation between the treating physician and the payer's medical director to clinically justify a denied service.
A payer denies a claim with reason code PR-1: 'Deductible Amount.' This denial should be classified as:
Answer: A contractual adjustment that is the patient's financial responsibility
PR-1 (Patient Responsibility - Deductible) indicates the patient owes this amount per their plan design, and it should be billed to the patient rather than appealed.
What is the standard first-level internal appeal timeframe that health plans must follow under the ACA for urgent care claims?
Answer: 72 hours
Under the ACA, health plans must resolve urgent care appeals within 72 hours of receiving the appeal request.
Which of the following denial types is most commonly addressed by verifying eligibility at the time of service?
Answer: Coverage and eligibility denials
Coverage and eligibility denials result from patients not having active insurance, and verifying eligibility before service delivery is the primary prevention strategy.
When preparing a claim appeal, which element of a well-written appeal letter is most important for establishing authority?
Answer: The reference to the specific contract language or clinical guideline that supports coverage
Citing specific contract language, coverage criteria, or clinical guidelines establishes the legal and clinical authority for why the claim should be paid.
A provider suspects a payer is systematically denying claims for a specific service that is covered under the contract. What is the best course of action?
Answer: Conduct a denial trend analysis and escalate to the payer's provider relations representative
Identifying systematic denial patterns through trend analysis and escalating to payer relations is the appropriate strategy to address contract compliance issues.