MANAGING PROBLEM CLAIMS

Question 1

claims that have been refused due to technical errors or
patient coverage errors
already processed & sent to the payer

Answer 1

Denied claims

Question 2

How can denied claims be resolved at times?

Answer 2

Appealing the decision

Question 3

this type of claim requires follow up to determine the appropriate action

Answer 3

Delinquent claims

Question 4

How many days does delinquent claims typically refer to?

Answer 4

30-45 days old

Question 5

this type of claims have not been processed by the Payer –
only by Clearinghouse / or office system

Answer 5

Rejected claims

Question 6

reasons for claim rejections…

Answer 6

• Incorrect, invalid, or unspecific
• dx codes
• procedure code
• Incorrect or missing modifier
• Mismatched POS to type of service
• Missing provider or org NPI #

Question 7

an effective method for claims payment only when the payer indicates no claim on file

Answer 7

Resubmitting (rebilling) claims

Question 8

it’s a type of claim where the payer indicates no claim on file which could be sent to the wrong payer, and for paper claims includes claims lost in the mail

Answer 8

Lost claims

Question 9

allows you to address the reason for denial and determine how to correct the claim

Answer 9

Review claim rejections and denials

Question 10

process used for minor changes to a previously filed claim

Answer 10

Clerical Error Reopening (CER)

Question 11

What corrections can be made using CER?

Answer 11

▪ Modifiers
▪ Place of services codes
▪ Adding or changing dx codes
▪ Correcting the date of service (if within the same
year)
▪ Most procedure codes

Question 12

a request submitted to a third-party payer to reconsider a claim that has been paid incorrectly or denied

Answer 12

Appeal

Question 13

Can appeals be used for rejected claims?

Answer 13

Nope!

Question 14

What are the 2 reqs of appeal that the coding & billing specialist must be familiar with?

Answer 14

• Having knowledge of the claim details
• Being prepared to provide relevant details that support the claims

Question 15

this is important for future follow-up

Answer 15

Careful documentation of appeals

Question 16

What are the five-level appeal process of Medicare?

Answer 16

• Level 1 – Redetermine
• Level 2 – Reconsider
• Level 3 – Disposition
• Level 4 – Review
• Level 5 - Judicial

Question 17

• filed with the Medicare Administrative Contractor (MAC)
• can be online or in writing
• must be within izo of the initial
  claims determination

Answer 17

Redetermination

Question 18

• filed with the qualified independent contractor (QIC)
• in writing
• must be within 180 of the notice of redetermination

Answer 18

Reconsideration

Question 19

• filed with HHS OMHA
• by telephone or video teleconference, some cases, can be in-person
• must be within 60 days of the
  reconsideration decision

Answer 19

Disposition
by Office of Medicare Hearings and Appeals (OMHA)

Question 20

• filed with the coundil in writing
• must be within 60 calendar days of the OMHA decision

Answer 20

Review
by the Medicare Appeals Council (Council)

Question 21

• filed in a district court according to the details provided by the council’s response
• must be within 60 days of the
  Council’s decision

Answer 21

Judicial
review in U.S. district Court

Question 22

What form must request for redetermination of Medicare claims use for submission?

Answer 22

CMS-20027 (Medicare Redetermination Request Form)

Question 23

indicates the viability of an organization’s revenue cycle, much like a report card for a student

Answer 23

accounts receivable by age reports

Question 24

arranges billed amounts by the length of time that has gone by without payment

Answer 24

Aging report

Question 25

A healthy aging report should have the largest amount of
balances owed under what date ranges?

Answer 25

1-30 days

Question 26

it is the investigative part of the revenue cycle process

Answer 26

Accounts receivable management

Question 27

Where you should referred to when determining patient responsibility or if the reimbursement is considered as payment in full?

Answer 27

fee schedule and the ERA (Electronic Remittance Advice) /EOB (Explanation of Benefits)

Question 28

Where should we refer to when determining patient responsibility or if the reimbursement is considered as payment in full?

Answer 28

fee schedule and the ERA (Electronic Remittance Advice) /EOB (Explanation of Benefits)

Question 29

What is a payer mixer?

Answer 29

how many patients of each payer the organization provides care to

Question 30

it’s when cannot collect monies or the patient have not paid over a long period of time

Answer 30

Bad debt