Denial Management & Appeals Flashcards
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Read the first 7 Denial Management & Appeals flashcards as text
Which denial reason code indicates that a claim was rejected because the service is not covered under the patient's plan?
Answer: CO-96
CO-96 is the CARC (Claim Adjustment Reason Code) used when a service is not covered under the patient's plan or benefit package.
What is the first step a biller should take when a claim is denied due to 'coordination of benefits' (COB)?
Answer: Verify primary and secondary insurance information and resubmit in correct order
When a claim is denied for COB issues, the biller must verify which payer is primary and which is secondary, then resubmit claims in the correct order.
A claim is denied with reason code CO-29. What does this mean?
Answer: The time limit for filing has expired
CO-29 indicates the claim was denied because it was filed after the payer's timely filing deadline.
Which document is most important to include when appealing a claim denied for 'medical necessity'?
Answer: Physician's clinical documentation and supporting medical records
Medical necessity appeals require clinical documentation such as physician notes, test results, and treatment plans to justify that the service was medically necessary.
What is a 'timely filing' denial, and what is the typical remedy?
Answer: A denial because the claim was submitted after the payer's deadline; remedy is providing proof of timely submission
Timely filing denials occur when claims are submitted past the payer's deadline; billers can appeal by providing proof (e.g., electronic submission reports) that the claim was sent within the allowed window.
Which of the following best describes a 'soft denial'?
Answer: A denial that can be corrected and resubmitted without a formal appeal
A soft denial is a temporary or correctable denial that can be resolved by submitting additional information or correcting errors without going through a formal appeal process.
When a payer denies a claim stating 'duplicate claim,' what should the biller do first?
Answer: Verify whether the original claim was already paid or is still pending before resubmitting
Before resubmitting, the biller should check the payer's records or remittance advice to confirm whether the original claim was paid, pending, or truly a duplicate error.