Denials, appeals, and collections
Denials, appeals, and collections
This domain tests what happens after a claim is not paid as expected: denial classification, root-cause correction, appeal rights and deadlines, A/R follow-up, and lawful patient collection. Expect questions on remittance codes, Medicare appeal levels, documentation packets, and collection-practice rules.
Rules and concepts
- Read the remittance advice. CARC and RARC codes identify the reason and the action: correct and resubmit, appeal, bill the patient, or write off according to policy.
- Common denial families include eligibility, authorization, coding, medical necessity, timely filing, coordination of benefits, duplicate claims, bundling, and noncovered services.
- Correctible errors usually go back as a corrected claim; clinical or policy disputes go through appeal. Do not appeal an obvious data error without fixing it.
- Medicare appeal sequence: redetermination by the MAC, reconsideration by the QIC, ALJ hearing, Medicare Appeals Council, then judicial review, each with its own deadline and amount threshold. Commercial payer levels and timeframes vary by contract.
- A strong appeal includes the denial, appeal letter, medical record, proof of timely filing, authorization, and a specific rationale tied to the payer's policy.
- Collections must follow FDCPA limits for third-party collectors, TCPA consent rules for calls or texts, FCRA rules for credit reporting, and state law. Screen for financial assistance and charity care before aggressive collection.
Worked example
A claim is denied with CARC 16, "claim lacks information." The denial is not a medical necessity dispute. The biller checks the claim and finds the referring NPI missing, corrects the claim, and resubmits within the payer's filing deadline. By contrast, a denial stating that a procedure was not medically necessary requires clinical documentation and an appeal, not a simple resubmission.
Traps
Appealing a correctable data error; missing the appeal deadline; ignoring CARC/RARC detail; writing off a balance without checking patient responsibility; failing to document collection contacts; and using collection tactics that violate FDCPA, TCPA, or state rules.