CPB Certification Chapter 13
Services that are appropriate to the evaluation and treatment of a disease, condition, illness
or injury and consistent with the applicable standard of care are considered what? - correct
answer-Medically necessary
A denial is received in the office for timely filing. The payer has a 60-day timely filing policy
for appeals. The internal process is investigated and it is found that the appeal was filed at
90 days. What can be done? - correct answer-Write off the claim amount
If a claim is not submitted within the parameters the payer has set for timely filing, the claim
must be written off. The patient cannot be balance billed.
What is one way to assist in lowering denials for non-covered services? - correct answer-Be
aware of the most common exclusions in the office's major plans
A biller cannot be expected to know every exclusion that each plan carries, but should be
aware of the most common exclusions in the major plans that their office contracts with to
ensure avoidance of this issue, when possible. Appeals for non-covered services are futile.
CPT codes 11400 and 12031 were reported on a claim. The insurance carrier denied 12031
as bundled with 11400. According to CPT® guidelines for Excision for Benign Lesions what
action should the biller take? - correct answer-Appeal the claim.
According to the CPT guidelines, intermediate and complex repairs may be reported
separately, in addition to, an excision. CPT® code 12031 is for an intermediate repair. The
biller should appeal the decision.
According to Aetna's published guidelines, what is the timeframe for filing an appeal? -
correct answer-Within 60 days of the prior decision
Which of the following modifiers will appropriately bypass the NCCI bundling edits?
I. Modifier 25
II. Modifier 52
III. Modifier 62
IV. Modifier 58 - correct answer-I, IV
The modifiers that can be used to bypass NCCI edits include 24,25,27,57,58,59,78,79, and
91
What will happen if a claim for a service that the payer requires prior authorization for is sent
without the prior authorization? - correct answer-It will be denied
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
Services that are appropriate to the evaluation and treatment of a disease, condition, illness
or injury and consistent with the applicable standard of care are considered what? - correct
answer-Medically necessary
A denial is received in the office for timely filing. The payer has a 60-day timely filing policy
for appeals. The internal process is investigated and it is found that the appeal was filed at
90 days. What can be done? - correct answer-Write off the claim amount
If a claim is not submitted within the parameters the payer has set for timely filing, the claim
must be written off. The patient cannot be balance billed.
What is one way to assist in lowering denials for non-covered services? - correct answer-Be
aware of the most common exclusions in the office's major plans
A biller cannot be expected to know every exclusion that each plan carries, but should be
aware of the most common exclusions in the major plans that their office contracts with to
ensure avoidance of this issue, when possible. Appeals for non-covered services are futile.
CPT codes 11400 and 12031 were reported on a claim. The insurance carrier denied 12031
as bundled with 11400. According to CPT® guidelines for Excision for Benign Lesions what
action should the biller take? - correct answer-Appeal the claim.
According to the CPT guidelines, intermediate and complex repairs may be reported
separately, in addition to, an excision. CPT® code 12031 is for an intermediate repair. The
biller should appeal the decision.
According to Aetna's published guidelines, what is the timeframe for filing an appeal? -
correct answer-Within 60 days of the prior decision
Which of the following modifiers will appropriately bypass the NCCI bundling edits?
I. Modifier 25
II. Modifier 52
III. Modifier 62
IV. Modifier 58 - correct answer-I, IV
The modifiers that can be used to bypass NCCI edits include 24,25,27,57,58,59,78,79, and
91
What will happen if a claim for a service that the payer requires prior authorization for is sent
without the prior authorization? - correct answer-It will be denied
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
