Ch 13: Commercial Insurance Carriers

Question 1

Which modifier is used to indicate that an E/M service is unrelated to the global service?

Answer 1

24: Unrelated E/M by the same physician or other QHP during the Postop Period

Question 2

What is a rejected claim?

Answer 2

a claim that does not contain the necessary information for adjudication
rejected by warehouse

Question 3

What denial occurs when the claim is a liability case and was submitted to the health insurance?

Answer 3

Claim covered by other insurer

Question 4

Significant, separately identifiable E/M by the same physician or other QHP on the same day of the procedure or other service is which modifier?

Answer 4

25

Question 5

Which denial is one of the leading reasons a claim is denied and can be prevented by accurate intake information being collected every time?

Answer 5

Incorrect patient information

Question 6

What’s the different between a Rejected Claim and a Denied Claim?

Answer 6

Rejected: a claim not containing the necessary information for adjudication (warehouse)
Denied: passed through the payers initial processing but was determined not to be a covered service or procedure (insurance)

Question 7

Which Modifiers can be used to bypass bundling edits for services during global period that are unrelated?

Answer 7

Mod 24, 25, 58, 59, 78, 79

Question 8

Patient Protection & Affordable Care Act (ACA)

Answer 8

provides provisions for appeals process by health insurer. Process must include:
- appeal process
- notice to enrollees
- allows enrollee to review and present evidence
- external review process

Question 9

If a provider wishes to submit for a single-level provider payment review from Cigna, what is the timeframe for this type of dispute?

Answer 9

180 days - single-level review must be initiated within 180 days from the date of initial payment or denial decision from Cigna

Question 10

What information/documents are required for submitting an appeal to Cigna?

Answer 10

Original EOB, completed appeal form, and documentation that justifies why the decision should be reversed.

Question 11

If a denial is received on UHC claim, a reconsideration
must be submitted within what timeframe of the date of the EOB/RA?

Answer 11

within 12months of the date of EOB/RA

Question 12

For Aetna, how long does a provider have to file a reconsideration? What’s Aetna’s turn around time?

Answer 12

180 cal days of the initial claim decision.
Turn around = 3-5 business days from received.
30 business days of received if review by speciality unit.

Question 13

For Aetna, how long does a provider have to file an appeal? What’s Aetna’s turn around time?

Answer 13

within 60 cal days.
Turn around = 60 business days or received.
if additional info is needed, within 60 cal days from received.

Question 14

Services that are appropriate to evaluation and treatment of a disease, condition, illness or injury and consistent with the applicable standard of care are considered what?

Answer 14

Medical necessity

Question 15

On 05/02/20, a claim for an excision of a chest wall tumor, including ribs was reported with CPT Code 19260 and ICD-10-CM code D49.89 for DOS 05/01/2020. Why would the claim be denied?

Answer 15

CPT 19260 was deleted in 2020
it would be denied for invalid CPT for DOS

Question 16

What is one way to assist in lowering denials for non-covered services?

Answer 16

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.

Question 17

If a claim is denied, investigated, and found to be denied in error, what should a biller do?

Answer 17

Appeal the claim.

Question 18

Which regulations require a health insurer offering group or individual coverage to implement an effective appeal process for appeals of coverage determinations and claims?

Answer 18

Patient Protection and Affordable Care Act - it provides provisions for the appeals process. (Guidelines/policy/steps to an appeal)

Question 19

An initial denial is received 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?

Answer 19

Submit a reconsideration - AKA a formal review of a claim’s reimbursements.

Question 20

According to Cigna, what is the best way to resolve claim processing errors?

Answer 20

Contacting the claim service center.
- contractual disputes for denials and payment disputes are resolved through single level appeals

Question 21

What can be done in the practice to ensure that liability denials will not be received?
* liability = who is responsible?*

Answer 21

Liability issues can be avoided with a thorough intake of the patient at the time of service.
Dont assume the commercial insurance should be billed or that the patient was injured at work.

Question 22

What rejections/denials are the easiest to prevent with good front office policy?

Answer 22

• incorrect patient information
• eligibility expiration
• liability denials

Question 23

What does it mean if a claim is denied for Prior Authorization/ referral not received?

Answer 23

Some commercial plans require an authorization to be obtained prior to services being rendered for:
nonemergent procedures
nonemergent admissions
radiology services
* HMOs require referrals
*** Authorization number is entered in item 23 on the CMS-1500 form

Question 24

What should be done when a denial is received that states there is a global surgery package bundling issue?

Answer 24

check RBRVS, CPT, and payer policies

Question 25

Which modifiers will appropriately bypass the NCCI bundling edits?

Answer 25

24, 25, 27, 57, 58, 59, 78, 79, and 91

Question 26

According to Cigna’s appeal process, how many levels of internal appeals are offered?

Answer 26

One - Cigna offers a single level appeal before going into arbitration
arbitration = settling a dispute

Question 27

A denial is received in the office for timely filing. The payer has a 60-day timely filing policy for appeals. The internal process is investigated and it is found that the appeal was filed at 90-days. What can be done?

Answer 27

Write off the claim amount since we missed the timely filing deadline.

Question 28

Which type of denial is more likely to happen when the patient is insured through an HMO?

Answer 28

No referral or no authorization denial.
* Authorization number must be entered in item 23 on the CMS -1500 claim form

Question 29

What is the process of determining which of two or more insurance policies will have the primary responsibility of processing a claim?

Answer 29

Coordination of benefits

Question 30

What type of claim can be appeals?

Answer 30

Denied Claim

Question 31

A denial is received in the office indicating that a service was billed and denied due to bundling issues. The medical record is obtained and, upon review, it is documented that the second procedure is a staged procedure that was planned at the time of the initial procedure. When the claim is reviewed, no modifier was attached to the codes on the claim. What should be done to resolve the claim?

Answer 31

Add modifier 58 to the procedure and follow the payers guidelines for appeals
Modifier 58 = used to indicate a procedure is staged/related to another procedure during the postoperative period

Question 32

which modifier is used to identify a distinct procedural service?

Answer 32

Modifier 59

Question 33

Which modifier is used for the unplanned return to the operating room by the same physician for a related procedure during the post operative period?

Answer 33

Modifier 78

Question 34

What is UHC Appeal Process?

Answer 34

1. Claim Reconsideration Requests
   Reconsideration can be filed on the phone, electronically or on paper with in 12 months of the date on the EOB or RA
2. Appeal
   UHC Appeal Form if Reconsideration is denied

Question 35

A patient is involved in an accident at work and their commercial insurance is billed. What type of denial will be received?

Answer 35

other coverage issue - this denial is seen when the claim is a liability case.

Question 36

What can be appealed in regards to a claim?

Answer 36

Coordination of benefits
- missing patient information & termination of coverage CANNOT be appealed.
- request for medical records is the right of the payer when request for payment is made by the provider.