Exam 17: Refunds and Appeals

If a claim is denied because additional information is needed to prove medical necessity, the medical office specialist should: A)bill the patient. B)write off the entire amount. C)ask the patient to write a letter explaining the situation. D)submit the required information and follow up with the carrier.

Qualified independent contractors must process a reconsideration within: A)30 days. B)60 days. C)90 days. D)180 days.

The patient is responsible for payment when a claim is denied in all of the following cases EXCEPT when: A)services were for treatment of an excluded preexisting condition. B)services were provided after coverage was canceled. C)services were provided that were not preauthorized. D)services were provided before coverage was in effect.

Credit balances and refunds are a result of an overpayment by the __________ or the insurance carrier.

When an objective, unbiased group of physicians reviews claims to determine what payment is adequate for the services provided, the process is called __________ .

Negative adjustments will __________ the balance, while positive adjustments will __________ the balance on a patient account.

Reasons to rebill an insurance claim include all of the following EXCEPT: A)the medical office specialist made a mistake on the claim. B)charges on the original claim were not detailed. C)the patient was not eligible when the initial claim was filed. D)some of the services provided to a patient were not billed on prior claims.

The statute of limitations for refunds in cases in which no contract language covers refunds is: A)2 years. B)4 years. C)5 years. D)7 years.

An appeal letter is more effective when the medical office specialist includes information about the federal and state laws that affect the claim submission.

Using the SOAP format, the documentation of vital signs, height, weight, and blood pressure is: A)subjective information. B)objective information. C)part of the assessment. D)part of the plan.

To be reconsidered for payment by qualified independent contractors (QICs), a claim must be for an amount greater than $100.

When appealing a denial made because the carrier doesn't believe the services were medically necessary, the medical office assistant should include information: A)from the patient's medical record. B)about payment from other carriers in similar cases. C)about the physician's time spent with the patient. D)about the patient's benefit plan.

Using the SOAP format, the physician's recommended treatment, testing, or therapy is: A)a subjective finding. B)an objective finding. C)part of the assessment. D)part of the plan.

Medicare carriers must process a redetermination within: A)30 days. B)60 days. C)90 days. D)180 days.

Using the SOAP format, the diagnosis made by the doctor is: A)subjective information. B)objective information. C)part of the assessment. D)part of the plan.

Why is documentation important?

According to ERISA, a plan must pay a claim or respond regarding its status within: A)30 days. B)60 days. C)90 days. D)1 year.

The first level of Medicare appeals is a request for: A)review by a qualified independent contractor. B)redetermination by the carrier. C)review by an administrative law judge. D)review by the state insurance commissioner.

What information should be included in an appeal letter?

Using the SOAP format, documentation of the physical examination performed by the physician is: A)subjective information. B)objective information. C)assessment information. D)the plan.