CPB Exam Review Ch 13
Which regulations require a health insurer offering group or individual coverage to implement
an effective appeal process for appeals of coverage determinations and claims? - correct
answer-Patient Protection and Affordable Care Act
An initial denial is received in the office 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? - correct answer-Submit a reconsideration
If a claim is denied, investigated and found to be denied in error, what should a biller do? -
correct answer-Appeal the claim
What will happen if the claim for a service that the payer requires prior authorization for is
sent without the prior authorization. - correct answer-It will be denied
What modifiers can be used to bypass NCCI edits? - correct answer-24, 25, 27, 57, 58, 59.
78, 79, and 91
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? - correct answer-Add modifier 58 to the
procedure and follow the payer's guidelines for appeals
What rejections/denials are the easiest to prevent with good front office policy? - correct
answer-Incorrect patient information
Eligibility expiration
Liability denials
A patient is involved in an accident at work and their commercial insurance is billed. What
type of denial will be received? - correct answer-Other coverage issue
What can be appealed - correct answer-A denied claim
According to Atenas published guidelines, what is the timeframe for filing an appeal? -
correct answer-Within 60 calendar days of the previous decision
What can be done in the practice to ensure that liability denials will not be received? - correct
answer-Perform thorough intakes on patients that present with injuries.
Under what federal act must insurance companies implement effective appeals processes? -
correct answer-The Patient Protection and Affordable Care Act
Which regulations require a health insurer offering group or individual coverage to implement
an effective appeal process for appeals of coverage determinations and claims? - correct
answer-Patient Protection and Affordable Care Act
An initial denial is received in the office 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? - correct answer-Submit a reconsideration
If a claim is denied, investigated and found to be denied in error, what should a biller do? -
correct answer-Appeal the claim
What will happen if the claim for a service that the payer requires prior authorization for is
sent without the prior authorization. - correct answer-It will be denied
What modifiers can be used to bypass NCCI edits? - correct answer-24, 25, 27, 57, 58, 59.
78, 79, and 91
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? - correct answer-Add modifier 58 to the
procedure and follow the payer's guidelines for appeals
What rejections/denials are the easiest to prevent with good front office policy? - correct
answer-Incorrect patient information
Eligibility expiration
Liability denials
A patient is involved in an accident at work and their commercial insurance is billed. What
type of denial will be received? - correct answer-Other coverage issue
What can be appealed - correct answer-A denied claim
According to Atenas published guidelines, what is the timeframe for filing an appeal? -
correct answer-Within 60 calendar days of the previous decision
What can be done in the practice to ensure that liability denials will not be received? - correct
answer-Perform thorough intakes on patients that present with injuries.
Under what federal act must insurance companies implement effective appeals processes? -
correct answer-The Patient Protection and Affordable Care Act
