CRCR Denial Management and Appeals 5 — Questions and Answers
Question 1: A provider files a timely appeal but the payer does not respond within the contracted turnaround time. What is the appropriate action?
- Resubmit the original claim as a new claim to restart the clock
- Document the non-response and escalate to the payer's provider relations department or file a complaint with the state insurance regulator (Correct answer)
- Write off the claim as an administrative loss
- Recode the services and submit a corrected claim
Correct answer: Document the non-response and escalate to the payer's provider relations department or file a complaint with the state insurance regulator
When a payer fails to respond within the contracted or regulatory timeframe, escalating through provider relations and filing a regulatory complaint are the appropriate remedies.
Question 2: Under ERISA, what is the maximum timeframe a plan has to respond to a standard (non-urgent) benefit claim appeal?
- 30 days
- 60 days (Correct answer)
- 90 days
- 180 days
Correct answer: 60 days
ERISA regulations require group health plans to respond to standard internal appeals within 60 days of receiving the appeal.
Question 3: Which of the following is an example of a 'clinical edit' denial?
- A claim denied because the patient's policy was terminated
- A claim denied because the diagnosis code does not support the medical necessity of the procedure billed (Correct answer)
- A claim denied due to duplicate submission
- A claim denied because the rendering provider is out-of-network
Correct answer: A claim denied because the diagnosis code does not support the medical necessity of the procedure billed
A clinical edit denial occurs when the diagnosis code(s) on the claim do not meet the payer's criteria to justify the medical necessity of the procedure performed.
Question 4: In managing Medicaid claim denials, which state-specific tool is most important for understanding covered services and billing policies?
- The Medicare Claims Processing Manual
- The state Medicaid fee schedule and provider manual (Correct answer)
- The AMA CPT codebook
- The payer's Evidence of Coverage document
Correct answer: The state Medicaid fee schedule and provider manual
Each state's Medicaid program is governed by its own provider manual and fee schedule, which outline covered services, billing requirements, and appeal procedures.
Question 5: What is the significance of the 'write-off rate' as a denial management KPI?
- It measures the speed at which denied claims are appealed
- It represents the percentage of denied claim value that is ultimately uncollected and written off (Correct answer)
- It tracks the number of claims submitted per provider per month
- It calculates the average age of accounts receivable
Correct answer: It represents the percentage of denied claim value that is ultimately uncollected and written off
The write-off rate reflects the proportion of denied claim dollars that are never recovered, indicating the financial impact of denials that cannot be successfully appealed or corrected.
Question 6: A Medicare claim is denied because the National Coverage Determination (NCD) does not cover the service for the billed diagnosis. Which of the following is the most appropriate appeal strategy?
- Request a waiver of liability and bill the patient if an ABN was signed (Correct answer)
- Recode the claim with a different diagnosis that is not listed in the NCD
- Submit the claim to the secondary payer without appealing to Medicare
- Add modifier -59 to bypass the NCD restriction
Correct answer: Request a waiver of liability and bill the patient if an ABN was signed
If an ABN was signed and Medicare's NCD excludes coverage for that diagnosis, the provider may shift liability to the patient and collect through a waiver of liability process.
Question 7: Which of the following best describes 'concurrent review' in the utilization management context that can affect denial rates?
- A retrospective audit of all claims paid in the prior quarter
- An ongoing payer review of a patient's continued inpatient stay to authorize additional days (Correct answer)
- A pre-service review conducted before elective procedures
- A post-discharge coding review performed by the HIM department
Correct answer: An ongoing payer review of a patient's continued inpatient stay to authorize additional days
Concurrent review is the real-time payer evaluation of an inpatient stay's medical necessity, and failure to participate can result in denial of additional inpatient days.
CRCR Denial Management and Appeals 5
A provider files a timely appeal but the payer does not respond within the contracted turnaround time.
What is the appropriate action?