CRCR CRCR - Certified Revenue Cycle Representative Program Denial Management and Appeals 3

Question 1

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

Accepted Answer

Clinical edit denial

Answer

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'?

Accepted Answer

The payer's clinical coverage policy or LCD

Answer

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?

Accepted Answer

Correct the claim information and resubmit as a corrected claim

Answer

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?

Accepted Answer

One

Answer

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?

Accepted Answer

Appeal using InterQual or Milliman criteria supporting the inpatient level of care

Answer

Submitting clinical criteria such as InterQual or Milliman evidence in the appeal demonstrates that the inpatient level of care met nationally recognized standards.

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR CRCR - Certified Revenue Cycle Representative Program Denial Management and Appeals 3