AAPC Denial Management & Appeals 2

Question 1

What is the purpose of an Explanation of Benefits (EOB) in the denial management process?

Accepted Answer

It details payer decisions including payment amounts, adjustments, and denial reasons

Answer

It serves as the patient's medical record

Answer

It is used to verify patient eligibility

Answer

It is the same as a remittance advice sent to providers

Question 2

Which type of appeal is submitted directly to an independent external reviewer when internal payer appeals are exhausted?

Accepted Answer

External appeal

Answer

Internal appeal

Answer

Grievance

Answer

Informal reconsideration

Question 3

A denial is received with remark code N130. What does this indicate?

Accepted Answer

Payment is issued based on a lesser of cost provision

Answer

Claim submitted with incorrect NPI

Answer

Procedure code inconsistent with modifier

Answer

Claim filed past the timely filing limit

Question 4

When building an appeal letter for a denied claim, which element is MOST critical to include?

Accepted Answer

A clear reference to the denied claim, clinical justification, and relevant policy language

Answer

The patient's insurance card photocopy

Answer

A list of other patients with similar treatments

Answer

The provider's tax ID and billing address only

Question 5

What does a denial with reason code PR-1 indicate?

Accepted Answer

Deductible amount applied — patient responsibility

Answer

The claim was filed out of network

Answer

Benefit maximum has been reached

Answer

Service requires prior authorization

Question 6

Which federal law gives patients the right to appeal health insurance claim denials?

Accepted Answer

ERISA and the ACA

Answer

HIPAA Privacy Rule only

Answer

The False Claims Act

Answer

COBRA

Question 7

A biller receives a denial for 'missing or invalid modifier.' What is the correct course of action?

Accepted Answer

Review the procedure code, determine the correct modifier, and resubmit a corrected claim

Answer

Write off the charge as a contractual adjustment

Answer

Send the claim to the patient with the full balance

Answer

File an external appeal immediately