CRCR Denial Management and Appeals 4

Question 1

Under Medicare's claim appeal process, which level allows for a hearing before an Administrative Law Judge (ALJ)?

Accepted Answer

Level 3 – ALJ Hearing

Answer

Level 3 of the Medicare appeals process is a hearing before an Administrative Law Judge, available when the disputed amount meets the minimum threshold.

Question 2

A claim is denied because the referring physician's NPI is missing from the claim form. On which box of the CMS-1500 form should the referring provider's NPI appear?

Accepted Answer

Box 17b

Answer

The referring provider's NPI is entered in Box 17b of the CMS-1500 claim form.

Question 3

What does 'exhaustion of internal remedies' mean in the context of health plan appeals?

Accepted Answer

The claimant has completed all required internal appeal levels before seeking external review

Answer

Exhaustion of internal remedies means the claimant has pursued and completed all levels of internal appeals required by the plan before they are eligible to request an external independent review.

Question 4

Which of the following best describes the role of a Recovery Audit Contractor (RAC) in the context of denial management?

Accepted Answer

They identify and recover improper payments made by Medicare through post-payment audits

Answer

RACs are CMS-contracted auditors that review paid Medicare claims to identify and recover overpayments made due to billing errors or medical necessity issues.

Question 5

A payer denies a claim citing a lack of prior authorization. The provider has documented proof that authorization was obtained verbally. What is the best next step?

Accepted Answer

Append the verbal authorization reference number and date to the appeal and request reconsideration

Answer

Documenting the verbal authorization with the reference number, date, and representative name in an appeal letter is the appropriate first step to reverse an authorization-related denial.

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR Denial Management and Appeals 4