Denials & Appeals
What is the most common reason for a denial
Missing or incomplete information on a claim
What is the purpose of insurance verification?
To confirm coverage and benefits before services are rendered.
What does ICD-10 stand for?
International Classification of Diseases, 10th Revision.
What does A/R Days measure?
The average number of days it takes to collect payment.
What is the first step in the revenue cycle?
Patient scheduling and registration.
What document is typically required when submitting an appeal?
An appeal letter and supporting documentation.
What is a common consequence of inaccurate registration?
Claim denials or payment delays.
What is the purpose of CPT codes?
To describe medical procedures and services.
What is considered a healthy clean claim rate?
Above 90%.
What law governs patient privacy in billing?
HIPAA
What is the time limit for submitting a Medicare appeal?
120 days from the date of the initial determination.
What tool helps estimate patient responsibility before service?
Patient cost estimator or financial clearance tool.
What is a common cause of coding-related denials?
Incorrect or missing diagnosis codes.
What does DNFB stand for?
Discharged Not Final Billed.
What is the purpose of a workflow audit?
To identify inefficiencies and compliance risks.
What does the denial code CO-97 indicate?
Procedure or service not paid separately.
What is the term for collecting payment before service?
Point-of-service collections.
What is the role of a charge description master (CDM)?
To standardize billing codes and prices.
What KPI tracks the percentage of claims paid on first submission?
First-pass resolution rate.
What is one benefit of automating claim scrubbing?
Fewer rejections and faster processing.
What is the first step in analyzing a denial trend?
Categorize denials by type and payer.
What is one strategy to reduce registration errors?
Standardized training and checklists.
What is the difference between HCPCS Level I and Level II codes?
Level I = CPT codes; Level II = supplies, equipment, and non-physician services.
What is one way to reduce A/R days?
Improve claim accuracy and follow-up processes.
What is revenue integrity?
Ensuring accurate documentation, coding, and billing to prevent revenue leakage.