AAPC Denial Management & Appeals

Question 1

Which denial reason code indicates that a claim was rejected because the service is not covered under the patient's plan?

Accepted Answer

CO-96

Answer

CO-4

Answer

CO-97

Answer

CO-45

Question 2

What is the first step a biller should take when a claim is denied due to 'coordination of benefits' (COB)?

Accepted Answer

Verify primary and secondary insurance information and resubmit in correct order

Answer

Write off the balance immediately

Answer

Send the claim to the patient for payment

Answer

Appeal the denial to the state insurance board

Question 3

A claim is denied with reason code CO-29. What does this mean?

Accepted Answer

The time limit for filing has expired

Answer

Duplicate claim submitted

Answer

Non-covered service

Answer

Authorization was not obtained

Question 4

Which document is most important to include when appealing a claim denied for 'medical necessity'?

Accepted Answer

Physician's clinical documentation and supporting medical records

Answer

Explanation of Benefits (EOB)

Answer

Patient's driver's license

Answer

Patient's signed financial agreement

Question 5

What is a 'timely filing' denial, and what is the typical remedy?

Accepted Answer

A denial because the claim was submitted after the payer's deadline; remedy is providing proof of timely submission

Answer

A denial because the patient has two insurances; remedy is COB resolution

Answer

A denial for duplicate billing; remedy is voiding the duplicate

Answer

A denial for missing modifiers; remedy is resubmitting with the correct modifier

Question 6

Which of the following best describes a 'soft denial'?

Accepted Answer

A denial that can be corrected and resubmitted without a formal appeal

Answer

A final denial that cannot be appealed

Answer

A denial issued by Medicare only

Answer

A denial that requires an attorney to resolve

Question 7

When a payer denies a claim stating 'duplicate claim,' what should the biller do first?

Accepted Answer

Verify whether the original claim was already paid or is still pending before resubmitting

Answer

Immediately bill the patient for the full amount

Answer

Submit a corrected claim with a different date of service

Answer

File a complaint with CMS