Ch13- Commercial Insurance Carriers Flashcards
(35 cards)
What is a rejected claim?
a. A claim that has passed through the payer’s initial claim processing and was determined not to be a covered service based on coverage criteria.
b. A claim that does not contain the necessary information for adjudication.
c. Both A & B
d. None of the above
b. A claim that does not contain the necessary information for adjudication.
Rationale: A rejected claim is a claim that does not contain the necessary information for adjudication.
Which modifier is used to indicate that an E/M service is unrelated to the global service?
a. 24
b. 25
c. 59
d. 79
a. 24
Rationale: Modifier 24 is an Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Healthcare Professional During a Postoperative Period.
Which denial occurs when the claim is a liability case and was submitted to the health insurance?
a. Coordination of Benefits
b. Request for medical records
c. Claim not covered by insurer
d. Claim covered by other insurer
d. Claim covered by other insurer
Rationale: Similar to a coordination of benefits denial, a claim covered by other insurer denial occurs when the claim is a liability case such as auto or work-related accident.
Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service is which modifier?
a. 50
b. 25
c. 33
d. 24
b. 25
Rationale: Modifier 25—Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Healthcare Professional on the Same Day of the Procedure or Other Service.
Which of the following denials is one of the leading reasons a claim is denied and can be prevented by accurate intake information being collected every time?
a. Medical necessity
b. Coordination of Benefits
c. Request for medical records not received
d. Incorrect patient information
d. incorrect patient information
Rationale: Submitting incorrect patient demographic information to the insurance payer is one of the leading reasons a claim is rejected. Accurate intake information is imperative to avoid typographical errors.
For Aetna, how long does a provider have to file a reconsideration?
a. 60 calendar days from the date of service
b. 180 calendar days from the date of service
c. 60 calendar days from the date of the initial claim decision
d. 180 calendar days from the date of the initial claim decision
d. 180 calendar days from the date of the initial claim decision
According to the policy above, if a denial is received on a UnitedHealthcare claim, a reconsideration must be submitted within what time frame of the date of the EOB or PRA?
a. 12 months
b.180 days
c. 90 days
d. 60 days
a. 12 months
When submitting an appeal to Cigna for timely filing, which of the following is NOT required?
a. Original EOB.
b. Completed appeal form.
c. Documentation to justify reversal of the decision.
d. The patient’s complete medical chart.
d. The patient’s complete medical chart.
Rationale: To file an appeal to Cigna, submit the original EOB, a completed appeal form, and documentation that justifies why the decision should be reversed. Multiple forms can be found on Cigna’s website for billing dispute resolutions, appeal requests, and provider payment reviews. Some states have specific forms, so it is always best to check your provider contract for the proper process.
Which of the following includes provisions for the appeals process?
a. Patient Protection and Affordable Care Act
b. Peer Review Improvement Act
c. Omnibus Budget
Reconciliation Act
d. Federal Claims Collection Act
a. Patient Protection and Affordable Care Act
Rationale: The Patient Protection and Affordable Care Act (ACA) provides provisions for the appeals process. Under Section 2719, a health insurer offering group or individual coverage has to implement an effective appeals process for appeals of coverage determinations and claims.
If a provider wishes to submit for a single level provider payment review from Cigna, what is the timeframe for this type of dispute?
A.60 days
B.90 days
C.180 days
D.365 days
C. 180 days
Under what Federal Act must insurance companies implement effective appeals processes?
A. The Health Insurance Policies Act
B. The Patient Protection and Affordable Care Act
C. The Federal Records Act
D. The Social Security Act
B. The Patient Protection and Affordable Care Act
Which of the following can be appealed regarding a claim?
A. Timely filing
B. Request for medical records
C. Missing patient information
D. Termination of coverage
A. Timely filing
Rationale: Claims with missing patient information and termination of coverage are rejections and cannot be appealed. A request for medical records is the right of the payer when request for payment is made by a provider.
What is one way to assist in lowering denials for non-covered services?
A. Appeal all non-covered service denials
B. Call insurance companies before any services are rendered
C. Be aware of the most common exclusions in the office’s major plans
D. Keep every payer policy on file
C. Be aware of the most common exclusions in the office’s major plans
Rationale: A biller cannot be expected to know every exclusion that each plan carries but should be aware of the most common exclusions in the major plans that their office contracts with to ensure avoidance of this issue, when possible. Appeals for non-covered services are futile.
According to Aetna’s published guidelines, what is the timeframe for filing an appeal?
A. Within 60 calendar days of the initial claim decision
B. Within 180 calendar days of the initial claim decision
C. Within 60 calendar days of the previous decision
D. Within 30 calendar days of the previous decision
C. Within 60 calendar days of the previous decision
Rationale: According to Aetna’s timeframe for submission and response to reconsiderations and appeals, appeals must be filed within 60 calendar days of the previous decision.
What will happen if a claim for a service that the payer requires prior authorization for is sent without the prior authorization?
A. The payer will call regarding the authorization
B. It will be denied
C. It will still be paid
D. It will be paid at a reduced rate
B. It will be denied
Rationale: A claim will be denied if prior authorization or precertification data is not obtained or is missing on the claim.
If a claim is denied, investigated, and found to be denied in error, what should a biller do?
A. Refile the claim
B. Write the claim off
C. Balance bill the patient
D. Appeal the claim
D. Appeal the claim
Rationale: If a claim is denied, investigated, and found to be denied in error, an appeal should be filed. A biller needs to have a solid knowledge of each plan they appeal to, including filing deadlines.
CPT codes 11400 and 12031 were reported on a claim. The insurance carrier denied 12031 as bundled with 11400. According to CPT® guidelines for Excision for Benign Lesions what action should the biller take?
A. Appeal the claim
B. Add modifier 59 to 12031 and submit a corrected claim
C. Add modifier 51 to 12031 and submit a corrected claim
D. Write-off 12031 as repairs are included in excisions
A. Appeal the claim
Rationale: According to the CPT guidelines, intermediate and complex repairs may be reported separately, in addition to, an excision. CPT® code 12031 is for an intermediate repair. The biller should appeal the decision.
What is the process of determining which of two or more insurance policies will have the primary responsibility of processing a claim?
A. Participation
B. Authorization
C. Covered services
D. Coordination of benefits
D. Coordination of benefits
Rationale: Coordination of benefits is the process of determining which of two or more insurance policies will have the primary responsibility of processing a claim and the extent to which the other policies will contribute.
Which regulations require a health insurer offering group or individual coverage to implement an effective appeal process for appeals of coverage determinations and claims?
A. False Claims Act
B. Patient Protection and Affordable Care Act
C. Prompt Payment Act
D. Health Insurance Portability and Accountability Act
B. Patient Protection and Affordable Care Act
Rationale: The Patient Protection and Affordable Care Act provides provisions for the appeals process. Under Section 2719, a health insurer offering group or individual coverage has to implement an effective appeal process for appeals of coverage determinations and claims.
What should be done when a denial is received that states there is a global surgery package bundling issue?
A. Write it off
B. Appeal
C. Look at RBRVS only
D. Check RBRVS, CPT, and the payer’s policies
D. Check RBRVS, CPT, and the payer’s policies
Rationale: For bundled service and global surgery denials, RBRVS and CPT guidelines should be reviewed to determine if the services are bundled. Some payers do not follow RBRVS, so payer-specific contracts or policies may need to be reviewed for this information.
An initial denial is received in the office from Aetna. The denial is investigated and the office considers that the payment was not according to their contract. According to Aetna’s policy, what must the biller do?
A. Refile the claim
B. Submit a Reconsideration
C. Submit a Level 2 appeal
D. Submit a Level 1 appeal
B. Submit a Reconsideration
Rationale: According to Aetna’s appeals process, a Reconsideration is a formal review of a claim’s reimbursements. If a provider believes that they were paid at an incorrect rate, paid not according to their contract, and/or invalid or incorrect coding decisions; they may ask for reconsideration on the claim. Claims that require reprocessing may require additional documentation, if necessary.
What are some ways to avoid missing/invalid code denials on submitted claims?
I. QA coding staff
II. Code the same way all the time
III. Offer education to coding staff
IV. Use current year coding books
A. I, III
B. I, III, IV
C. I, IV
D. I, II, III
B. I, III, IV
Rationale: Current coding materials (books, software, encoders, etc.) should always be used to ensure that the most current codes are assigned on a claim. A biller needs to understand when other codes are required by a payer, such as HCPCS Level II codes by Medicare or other carriers, and Category III codes versus unlisted or other CPT® codes. QA of coding should be performed on a routine basis for all staff that assign codes. Education should be offered on coding and billing so staff can keep up with the latest methodologies and guidelines.
A patient is involved in an accident at work and their commercial insurance is billed. What type of denial will be received?
A. Non-covered service
B. Coordination of benefits issue
C. Prior authorization issue
D. Other Coverage issue
D. Other Coverage issue
Rationale: Similar to a coordination of benefits issue, this denial is seen when the claim is a liability case. When a patient has had an auto or work-related accident, the commercial insurance plan will deny coverage until the workers’ compensation, auto insurance, or other liability carrier has been billed.
Claim rejections are due to what?
A. Claims that do not contain necessary information for adjudication
B. Claims that do not meet coverage criteria
C. Claims that require medical record documentation
D. Claims that are already adjudicated
A. Claims that do not contain necessary information for adjudication
Rationale: A rejected claim is a claim that does not contain the necessary information for adjudication. Once the claim is resubmitted correctly, the claim will be processed.
