CRCR Claims Processing and Reimbursement 4 — Questions and Answers
Question 1: A claim is denied because the procedure code is inconsistent with the patient's gender. What type of edit triggered this denial?
- Age-related edit
- Gender-specific edit (Correct answer)
- Frequency edit
- Duplicate claim edit
Correct answer: Gender-specific edit
Gender-specific edits flag procedures that are anatomically impossible or inappropriate for the reported patient gender.
Question 2: Which Medicare claim form is used by institutional providers such as hospitals and skilled nursing facilities?
- CMS-1500
- UB-04 (CMS-1450) (Correct answer)
- ADA Dental Claim Form
- CMS-1490S
Correct answer: UB-04 (CMS-1450)
The UB-04 (CMS-1450) is the standard institutional claim form used by hospitals, SNFs, and other facility providers.
Question 3: A payer applies a coordination of benefits (COB) adjustment and pays only $150 of a $400 allowed amount because another plan paid $250. This COB method is called:
- Non-duplication method (Correct answer)
- Carve-out method
- Birthday rule method
- Maintenance of benefits method
Correct answer: Non-duplication method
Under the non-duplication method, the secondary payer pays nothing if the primary payer's payment equals or exceeds the secondary plan's allowable amount.
Question 4: What is the purpose of the National Uniform Billing Committee (NUBC)?
- To set physician fee schedules nationally
- To maintain and update the UB-04 data set and billing standards (Correct answer)
- To adjudicate Medicare claims for institutional providers
- To certify revenue cycle professionals
Correct answer: To maintain and update the UB-04 data set and billing standards
The NUBC maintains the UB-04 claim form data set and establishes uniform billing standards for institutional healthcare providers.
Question 5: A hospital submits a claim for an inpatient stay but failed to obtain pre-authorization. The payer denies the claim as 'not medically necessary.' What is the best first step?
- Write off the balance immediately
- File a formal complaint with the state insurance commissioner
- Appeal the denial with clinical documentation supporting medical necessity (Correct answer)
- Rebill the claim with a different diagnosis code
Correct answer: Appeal the denial with clinical documentation supporting medical necessity
Appealing with supporting clinical documentation is the appropriate first step to challenge a medical necessity denial.
Question 6: Which of the following describes 'split billing'?
- Billing two payers simultaneously for the same service
- Dividing a single service into multiple claim lines to increase reimbursement
- Separating a claim by date of service across two billing periods (Correct answer)
- Submitting the same claim to both Medicare and Medicaid
Correct answer: Separating a claim by date of service across two billing periods
Split billing involves dividing a claim across billing periods, often at month-end, to ensure all services within a period are captured correctly.
Question 7: Under the Medicare Outpatient Prospective Payment System (OPPS), what are Ambulatory Payment Classifications (APCs)?
- Groups of inpatient diagnoses used to set DRG weights
- Payment groups for outpatient services with similar clinical and resource characteristics (Correct answer)
- Capitation rates paid to primary care physicians
- Codes used to classify long-term care facility stays
Correct answer: Payment groups for outpatient services with similar clinical and resource characteristics
APCs are Medicare's payment groups for outpatient hospital services, where services with similar clinical characteristics and resource use are grouped together for a fixed payment.
CRCR Claims Processing and Reimbursement 4
A claim is denied because the procedure code is inconsistent with the patient's gender.
What type of edit triggered this denial?