Ch13- Commercial Insurance Carriers Flashcards
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.
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.
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. 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 timeframe 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.
