Exam 17: Refunds and Appeals

Credit balances and refunds result from __________ by patients and third-party payers.

If a patient is upset about a claim denial, the medical office specialist should do all of the following EXCEPT: A)explain in simple language why the insurance carrier denied payment. B)ask the patient to call the insurance carrier to try to get them to reconsider. C)use respect and care when explaining policy benefits. D)if the denial was due to a need for additional information, submit the additional documentation immediately and let the patient know it has been done.

A provider has 120 days to file a request with the Medicare carrier for a redetermination on a denied claim.

Where can a medical office specialist find sample appeal letters?

All of the following claims can be appealed by telephone EXCEPT those in which: A)a modifier was used to indicate multiple procedures that the carrier bundled. B)the claim was considered not medically necessary. C)the carrier requested information from the patient that was not received. D)the patient had a routine service covered by the policy.

In general, Medicaid can request refunds for overpayments to providers for up to: A)180 days. B)1 year. C)3 years. D)5 years.

A negative adjustment to a patient account will decrease the balance owed.

When payment is denied, the insurance carrier only notifies the patient.

What are the three levels of Medicare appeals?

When a carrier denies a claim because it determines that another carrier should be the primary payer, __________ of benefits is needed to determine the responsibility of each payer.

What is a claim appeal?