CRCR Claims Processing and Reimbursement 4

Question 1

A claim is denied because the procedure code is inconsistent with the patient's gender. What type of edit triggered this denial?

Accepted Answer

Gender-specific edit

Answer

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?

Accepted Answer

UB-04 (CMS-1450)

Answer

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:

Accepted Answer

Non-duplication method

Answer

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)?

Accepted Answer

To maintain and update the UB-04 data set and billing standards

Answer

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?

Accepted Answer

Appeal the denial with clinical documentation supporting medical necessity

Answer

Appealing with supporting clinical documentation is the appropriate first step to challenge a medical necessity denial.

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR Claims Processing and Reimbursement 4