Appeals Process Assignment Answer Key
For each reason, indicate the appropriate action (Accept, Resubmit, or Appeal). Then,
provide the rationale for your decision using the rationale code in the Rationale Options
section below the table (for example, D1).
Indicate One of the
Following Actions:
Accept
Reason for Denial, Rejection, or Partial Resubmit Provide Rationale
Payment Appeal for Decision:
The wrong diagnosis or procedure code was Resubmit D1
submitted.
The service provided is only allowed once Accept E1
every 3 year
m
er as
The payer determined the procedure to be Appeal B1
experimental.
co
The services rendered do not meet Medical Resubmit B2
eH w
Necessity.
o.
The diagnosis or procedure code(s) were Resubmit A1
missing.
rs e
The procedure performed is not a covered Appeal A2
ou urc
benefit for the patient.
Information is missing or incomplete. No Resubmit A1
additional information is available.
o
The service provided is paid at only 80% of Accept C2
charges.
aC s
The claim was filed without the insurance Resubmit C1
vi y re
carrier’s policy number on the CMS-1500
claim form.
An expensive drug was administered in the Accept D2
hospital setting for the patient’s
ed d
convenience rather than in the provider’s
ar stu
office.
The patient had suture removed in the local Accept E2
Emergency Room following a procedure
performed in the physician’s office. Suture
is
removal is part of the surgical package.
Th
Rationale Options
sh
Rationale to Appeal or Resubmit
Rationale Code to Enter in Table Above
The documentation has been reviewed and A1
additional diagnosis/procedure codes appended to
the account based on the documentation available in
the patient’s medical record.
A new (experimental) procedure requiring an B1
This study source was downloaded by 100000805705997 from CourseHero.com on 11-13-2021 02:46:17 GMT -06:00
https://www.coursehero.com/file/20752990/HIM2133-Module-4-Appeals-Process/
For each reason, indicate the appropriate action (Accept, Resubmit, or Appeal). Then,
provide the rationale for your decision using the rationale code in the Rationale Options
section below the table (for example, D1).
Indicate One of the
Following Actions:
Accept
Reason for Denial, Rejection, or Partial Resubmit Provide Rationale
Payment Appeal for Decision:
The wrong diagnosis or procedure code was Resubmit D1
submitted.
The service provided is only allowed once Accept E1
every 3 year
m
er as
The payer determined the procedure to be Appeal B1
experimental.
co
The services rendered do not meet Medical Resubmit B2
eH w
Necessity.
o.
The diagnosis or procedure code(s) were Resubmit A1
missing.
rs e
The procedure performed is not a covered Appeal A2
ou urc
benefit for the patient.
Information is missing or incomplete. No Resubmit A1
additional information is available.
o
The service provided is paid at only 80% of Accept C2
charges.
aC s
The claim was filed without the insurance Resubmit C1
vi y re
carrier’s policy number on the CMS-1500
claim form.
An expensive drug was administered in the Accept D2
hospital setting for the patient’s
ed d
convenience rather than in the provider’s
ar stu
office.
The patient had suture removed in the local Accept E2
Emergency Room following a procedure
performed in the physician’s office. Suture
is
removal is part of the surgical package.
Th
Rationale Options
sh
Rationale to Appeal or Resubmit
Rationale Code to Enter in Table Above
The documentation has been reviewed and A1
additional diagnosis/procedure codes appended to
the account based on the documentation available in
the patient’s medical record.
A new (experimental) procedure requiring an B1
This study source was downloaded by 100000805705997 from CourseHero.com on 11-13-2021 02:46:17 GMT -06:00
https://www.coursehero.com/file/20752990/HIM2133-Module-4-Appeals-Process/
