CRCR Denial Management and Appeals 2

Question 1

A claim is denied with reason code CO-4. What does this denial indicate?

Accepted Answer

The procedure code is inconsistent with the modifier

Answer

CO-4 indicates the service was denied because the procedure code is inconsistent with the modifier used on the claim.

Question 2

Which of the following best describes a 'soft denial' in revenue cycle management?

Accepted Answer

A denial that can be resolved by submitting additional information or correcting the claim

Answer

A soft denial is a temporary denial that can be overturned by providing missing information, correcting errors, or submitting supporting documentation.

Question 3

When a payer denies a claim stating 'services not medically necessary,' what is the most critical document to include in an appeal?

Accepted Answer

A letter of medical necessity from the treating physician

Answer

A letter of medical necessity from the treating physician is the primary document needed to justify that the services were clinically appropriate.

Question 4

A hospital receives a denial for an inpatient stay coded as DRG 470 (Major Joint Replacement). The payer argues the patient did not meet criteria for inpatient admission. Which appeal strategy is most appropriate?

Accepted Answer

Submit clinical documentation supporting the inpatient level of care decision

Answer

Submitting clinical documentation that supports the inpatient admission criteria is the appropriate first step in appealing a medical necessity denial for an inpatient stay.

Question 5

Which federal regulation governs the external appeal process for patients enrolled in employer-sponsored health plans?

Accepted Answer

ERISA (Employee Retirement Income Security Act)

Answer

ERISA governs the claims and appeals process for most employer-sponsored group health plans, including the right to an external appeal.

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR Denial Management and Appeals 2