HAC Healthcare Insurance & Claims Processing 2

Question 1

A claim is denied with remark code CO-4. What does this denial reason indicate?

Accepted Answer

The procedure code is inconsistent with the modifier

Answer

CO-4 denials indicate that the procedure code submitted is inconsistent with the modifier used on the claim.

Question 2

Which document serves as the primary source of truth for determining a patient's covered benefits in a commercial insurance plan?

Accepted Answer

The Certificate of Coverage or Evidence of Coverage

Answer

The Certificate of Coverage (or Evidence of Coverage) is the legally binding document that defines all covered benefits, exclusions, and limitations under a plan.

Question 3

Under the coordination of benefits (COB) rules, the 'birthday rule' is used to determine which parent's plan is primary for a dependent child. If both parents have the same birthday, which plan is primary?

Accepted Answer

The plan of the parent who has been covered longer

Answer

When parents share the same birthday, the plan that has been in effect longer is designated as primary under the birthday rule tiebreaker.

Question 4

A provider submits a claim for 99214 and 99213 for the same patient on the same date of service. The payer rejects the second E/M code. Which rule is being applied?

Accepted Answer

Mutually exclusive edit

Answer

Payers apply mutually exclusive edits (often via NCCI) to deny two E/M services billed by the same provider for the same patient on the same date.

Question 5

What is the function of the 'crossover claim' in Medicare/Medicaid dual-eligible billing?

Accepted Answer

Medicare automatically forwards the claim to Medicaid after processing for secondary payment

Answer

For dual-eligible patients, Medicare processes the claim first and then automatically crossovers the EOB to Medicaid to pay the remaining patient liability.

(HAC) Healthcare Accounting Certification Practice Test

(HAC) Healthcare Accounting Certification Practice Test

HAC Healthcare Insurance & Claims Processing 2