CRCR Denial Management and Appeals 3

Question 1

Which of the following is considered a 'hard denial' in denial management?

Accepted Answer

A denial for services rendered after the patient's coverage termination date

Answer

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'?

Accepted Answer

A physician-to-physician conversation between the treating provider and the payer's medical reviewer to discuss a denied claim

Answer

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:

Accepted Answer

A contractual adjustment that is the patient's financial responsibility

Answer

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?

Accepted Answer

72 hours

Answer

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?

Accepted Answer

Coverage and eligibility denials

Answer

Coverage and eligibility denials result from patients not having active insurance, and verifying eligibility before service delivery is the primary prevention strategy.

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR Denial Management and Appeals 3