CBCS Denial Management and Appeals 2

Question 1

What is the first step a medical biller should take upon receiving a claim denial?

Accepted Answer

Identify the denial reason code and determine whether the denial is correctable, appealable, or valid

Answer

Immediately write off the denied amount

Answer

Resubmit the claim without changes

Answer

Contact the patient to collect the balance

Question 2

What is the difference between a claim denial and a claim rejection in terms of next steps?

Accepted Answer

Denied claims require a formal appeal through the payer's process; rejected claims are corrected and resubmitted as a new claim

Answer

Denials require a new claim number; rejections use the original claim number

Answer

Denials can only be handled by the provider; rejections can be handled by billing staff

Answer

There is no practical difference in next steps

Question 3

What is a peer-to-peer review in the context of insurance denials?

Accepted Answer

A physician-to-physician discussion between the treating provider and the payer's medical reviewer to discuss a denied or potentially denied service

Answer

A review of a coder's work by a fellow credentialed coder

Answer

A review process where two insurance companies assess the same claim

Answer

An audit where multiple billers review each other's work for quality

Question 4

What information should be included in a formal appeal letter for a denied claim?

Accepted Answer

Patient information, claim details, denial reason, clinical documentation supporting medical necessity, applicable policies/guidelines, and a specific request for reconsideration

Answer

Only the claim number and date of service

Answer

Only the physician's letter explaining why the service was necessary

Answer

The patient's complaint about the denial

Question 5

What is a corrected claim and when is it used?

Accepted Answer

A resubmission of a previously processed claim with corrections to errors, submitted with frequency code 7 (replacement) or 8 (void)

Answer

A new claim submitted after a denial, used instead of an appeal

Answer

A claim submitted on paper to replace an electronic claim

Answer

A claim submitted by the patient after the provider declines to refile

Question 6

What is the Medicare redetermination process?

Accepted Answer

The first level of Medicare's five-level administrative appeals process, where the Medicare Administrative Contractor reviews the claim denial

Answer

A Medicare audit process for identifying fraud

Answer

A process for reviewing Medicare premium calculations

Answer

A secondary billing process for Medicare crossover claims