CRCR Denial Management and Appeals 5

Question 1

A provider files a timely appeal but the payer does not respond within the contracted turnaround time. What is the appropriate action?

Accepted Answer

Document the non-response and escalate to the payer's provider relations department or file a complaint with the state insurance regulator

Answer

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?

Accepted Answer

60 days

Answer

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?

Accepted Answer

A claim denied because the diagnosis code does not support the medical necessity of the procedure billed

Answer

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?

Accepted Answer

The state Medicaid fee schedule and provider manual

Answer

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?

Accepted Answer

It represents the percentage of denied claim value that is ultimately uncollected and written off

Answer

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.

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR Denial Management and Appeals 5