CRCR CRCR - Certified Revenue Cycle Representative Program Denial Management and Appeals 3 — Questions and Answers
Question 1: A claim is denied because the procedure code is inconsistent with the patient's age. What type of denial is this?
- Contractual adjustment denial
- Clinical edit denial (Correct answer)
- Coordination of benefits denial
- Timely filing denial
Correct answer: Clinical edit denial
A clinical edit denial occurs when the billed procedure or diagnosis conflicts with patient demographics such as age or gender.
Question 2: Which document should a provider request first when a payer denies a claim citing 'not medically necessary'?
- The payer's fee schedule
- The payer's clinical coverage policy or LCD (Correct answer)
- The patient's insurance card
- The remittance advice remark code list
Correct answer: The payer's clinical coverage policy or LCD
Reviewing the payer's clinical coverage policy or Local Coverage Determination (LCD) identifies the criteria the payer uses to define medical necessity for that service.
Question 3: A payer issues a denial with CARC 16 and RARC N56. What action should the biller take?
- File a formal appeal with clinical documentation
- Correct the claim information and resubmit as a corrected claim (Correct answer)
- Write off the balance as a bad debt
- Contact the patient to collect the balance
Correct answer: Correct the claim information and resubmit as a corrected claim
CARC 16 indicates the claim contains missing or invalid information; RARC N56 points to a specific data element that must be corrected before the claim can be processed.
Question 4: Under the ACA, what is the maximum number of levels of internal appeals an insurer can require a member to exhaust before accessing external review?
- One (Correct answer)
- Two
- Three
- Four
Correct answer: One
The ACA limits insurers to requiring no more than one level of internal appeal before a member may request an independent external review.
Question 5: A hospital receives a denial for a 3-day inpatient stay stating the admission was not medically necessary but the services rendered were. What is the most appropriate appeal strategy?
- Accept the denial and bill the patient for the full amount
- Appeal using InterQual or Milliman criteria supporting the inpatient level of care (Correct answer)
- Recode the stay as observation and resubmit
- Request an immediate external review without an internal appeal
Correct answer: Appeal using InterQual or Milliman criteria supporting the inpatient level of care
Submitting clinical criteria such as InterQual or Milliman evidence in the appeal demonstrates that the inpatient level of care met nationally recognized standards.
Question 6: Which federal regulation requires Medicare Advantage plans to provide enrollees with a standardized notice of denial and appeal rights?
- HIPAA Privacy Rule
- The Stark Law
- CMS Medicare Managed Care Manual Chapter 13 (Correct answer)
- The False Claims Act
Correct answer: CMS Medicare Managed Care Manual Chapter 13
CMS Medicare Managed Care Manual Chapter 13 governs Medicare Advantage organization determinations, appeals, and grievances, including required denial notice language.
Question 7: A provider submits a claim for a bilateral procedure using modifier 50. The payer denies one unit as a duplicate. What is the correct corrective action?
- Resubmit the claim with modifier 59 on the second unit
- Appeal the denial and include documentation explaining bilateral coding guidelines (Correct answer)
- Write off the denied unit
- Report the payer to state insurance commissioner
Correct answer: Appeal the denial and include documentation explaining bilateral coding guidelines
Appealing with an explanation of bilateral procedure coding rules and clinical documentation showing both sides were treated supports payment for the correctly billed bilateral service.
CRCR CRCR - Certified Revenue Cycle Representative Program Denial Management and Appeals 3
A claim is denied because the procedure code is inconsistent with the patient's age.
What type of denial is this?