CRCR Denial Management and Appeals 3 — Questions and Answers
Question 1: Which of the following is considered a 'hard denial' in denial management?
- A denial pending additional clinical documentation
- A denial due to a missing modifier that can be corrected and resubmitted
- A denial for services rendered after the patient's coverage termination date (Correct answer)
- A denial requiring coordination of benefits verification
Correct answer: A denial for services rendered after the patient's coverage termination date
A hard denial for services rendered after coverage termination is generally not reversible because the patient had no active insurance on the date of service.
Question 2: During the appeal process, what is a 'peer-to-peer review'?
- A review conducted by two billing specialists to verify claim accuracy
- A physician-to-physician conversation between the treating provider and the payer's medical reviewer to discuss a denied claim (Correct answer)
- A committee review of all denials exceeding a set dollar threshold
- An audit of claims performed by CMS on behalf of the provider
Correct answer: A physician-to-physician conversation between the treating provider and the payer's medical reviewer to discuss a denied claim
A peer-to-peer review is a direct conversation between the treating physician and the payer's medical director to clinically justify a denied service.
Question 3: A payer denies a claim with reason code PR-1: 'Deductible Amount.' This denial should be classified as:
- A billing error requiring a corrected claim
- A contractual adjustment that is the patient's financial responsibility (Correct answer)
- A medical necessity denial requiring clinical appeal
- A timely filing denial requiring proof of timely submission
Correct answer: A contractual adjustment that is the patient's financial responsibility
PR-1 (Patient Responsibility - Deductible) indicates the patient owes this amount per their plan design, and it should be billed to the patient rather than appealed.
Question 4: What is the standard first-level internal appeal timeframe that health plans must follow under the ACA for urgent care claims?
- 72 hours (Correct answer)
- 30 days
- 60 days
- 180 days
Correct answer: 72 hours
Under the ACA, health plans must resolve urgent care appeals within 72 hours of receiving the appeal request.
Question 5: Which of the following denial types is most commonly addressed by verifying eligibility at the time of service?
- Medical necessity denials
- Timely filing denials
- Coverage and eligibility denials (Correct answer)
- Coding-related denials
Correct answer: Coverage and eligibility denials
Coverage and eligibility denials result from patients not having active insurance, and verifying eligibility before service delivery is the primary prevention strategy.
Question 6: When preparing a claim appeal, which element of a well-written appeal letter is most important for establishing authority?
- The provider's NPI number and tax ID
- The reference to the specific contract language or clinical guideline that supports coverage (Correct answer)
- The patient's demographic information
- The date the original claim was submitted
Correct answer: The reference to the specific contract language or clinical guideline that supports coverage
Citing specific contract language, coverage criteria, or clinical guidelines establishes the legal and clinical authority for why the claim should be paid.
Question 7: A provider suspects a payer is systematically denying claims for a specific service that is covered under the contract. What is the best course of action?
- Stop billing for that service entirely
- Conduct a denial trend analysis and escalate to the payer's provider relations representative (Correct answer)
- File individual appeals only when the denial amount exceeds $5,000
- Write off all denied claims to avoid audit risk
Correct answer: Conduct a denial trend analysis and escalate to the payer's provider relations representative
Identifying systematic denial patterns through trend analysis and escalating to payer relations is the appropriate strategy to address contract compliance issues.
CRCR Denial Management and Appeals 3
Which of the following is considered a 'hard denial' in denial management?