Chapter 1: Rejected and Denied Claims Flashcards

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1
Q

What are the two biggest obstacles affecting the revenue cycle are?

A

Insurance Claim Rejections and Claim Denials.

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2
Q

Does insurance companies can process rejected insurance claims as they were never entered into their computer systems?

A

No.

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3
Q

Why do insurance companies can’t process rejected insurance claims as they were never entered into their computer systems?

A

Because they fail to meet specific data requirements.

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4
Q

Who can correct the errors that insurance companies can’t process and resubmit the claim?

A

Office Staff.

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5
Q

What is the first error that insurance companies can’t process?

A

Data entry errors (YYP4013 entered as YYP4103).

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6
Q

What is the second error that insurance companies can’t process?

A

Incorrect patient gender (hysterectomy submitted for a male patient).

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7
Q

What is the third error that insurance companies can’t process?

A

Patient is unidentifiable (Beth entered instead of Elizabeth).

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8
Q

What is the fourth error that insurance companies can’t process?

A

Missing information (date of birth)

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9
Q

What is the fifth error that insurance companies can’t process?

A

Invalid medical code.

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10
Q

Denied claims, were received and processed by?

A

The payer and a negative determination made.

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11
Q

Does a denied claim can be resubmitted?

A

No.

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12
Q

If the claim cannot be resubmitted what requires to be resubmitted?

A

The provider to file an appropriate appeal or request reconsideration form the payer.

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13
Q

Does some denials require the patient to make payments directly to the provider?

A

Yes.

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14
Q

What is the first reason for denied claims?

A

Patient not covered by the policy on the date of service.

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15
Q

What is the second reason for denied claims?

A

Procedure or service is not medically necessary.

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16
Q

What is the third reason for denied claims?

A

Insurance company is not the primary payer.

17
Q

What is the fourth reason for denied claims?

A

Policy does not cover the service or procedure.

18
Q

What is the fifth reason for denied claims?

A

Prior authorization not obtained.

19
Q

What is the sixth reason for denied claims?

A

The payer’s time frame for filing a claim has passed.