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NHA CBCS practice questions

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Question 1Claims management

Under the CMS-1500 claim form structure, which section is used to report the diagnosis codes that support medical necessity for the services billed?

  1. Item 1, Type of Insurance
  2. Item 21, Diagnosis or Nature of Illness or Injury Correct answer.
  3. Item 24E, Diagnosis Pointer
  4. Item 33, Billing Provider Info

Explanation

Item 21 of the CMS-1500 is where ICD-10-CM diagnosis codes are entered to establish medical necessity. Item 24E only carries the pointer letters that link each service line back to those diagnoses.

Question 2Claims management

A patient's claim is denied because the service was provided before the payer's effective date of coverage. Which type of denial does this represent?

  1. Medical necessity denial
  2. Eligibility/coverage denial Correct answer.
  3. Timely filing denial
  4. Coding denial

Explanation

A denial tied to coverage effective dates is an eligibility/coverage denial because the payer is stating the patient was not covered on the date of service. Coding and medical necessity denials involve the content of the claim, and timely filing involves submission deadlines.

Question 3Claims management

What is the primary purpose of the remittance advice (RA) or 835 transaction in claims management?

  1. To authorize a referral to a specialist
  2. To verify patient eligibility before the visit
  3. To transmit the original claim from provider to payer
  4. To explain payment, adjustments, and denial reasons for submitted claims Correct answer.

Explanation

The remittance advice (paper) or 835 electronic remittance advice communicates adjudication results, including paid amounts, contractual adjustments, patient responsibility, and denial codes. Claim submission is handled by the 837P transaction, while eligibility uses 270/271.

Question 4Claims management

A claim is submitted with a procedure code that is not covered by the patient's specific Medicaid managed care plan, though it is covered by Medicare. This situation most directly involves which claims management concept?

  1. Clean claim submission
  2. Coordination of benefits order
  3. Appeal level hierarchy
  4. Payer-specific coverage determination Correct answer.

Explanation

Coverage varies by payer and plan, so a code payable under Medicare may be non-covered under a Medicaid managed care plan. Claims staff must verify each payer's coverage policies before submission to avoid denials.

Question 5Claims management

Which of the following best describes a 'clean claim'?

  1. A claim that has already been paid in full
  2. A claim with all required data elements that passes front-end edits without rejection Correct answer.
  3. A claim sent only by paper mail
  4. A claim submitted without any diagnosis codes

Explanation

A clean claim contains all required fields, valid codes, and correct formatting so it passes payer front-end edits and enters adjudication without rejection. Payment status and submission medium are unrelated to cleanliness.

Question 6Claims management

A claim is rejected by the payer's clearinghouse before adjudication because the patient's date of birth is missing. What is the appropriate first action?

  1. Correct the missing data element and resubmit the claim Correct answer.
  2. Write off the balance as bad debt
  3. File a formal appeal with the payer
  4. Bill the patient immediately for the full charge

Explanation

A front-end rejection is a data problem, not an adjudicated denial, so the fix is to correct the missing or invalid element and resubmit. Appeals and patient billing are premature until the claim has actually been processed and denied.

Question 7Claims management

In the CMS-1500 form, which item reports the patient's account number assigned by the provider?

  1. Item 26, Patient's Account No. Correct answer.
  2. Item 21, Diagnosis Codes
  3. Item 1a, Insured's ID Number
  4. Item 24B, Place of Service

Explanation

Item 26 is designated for the provider's internal patient account number, which helps reconcile payments and correspondence. Item 1a is the insured's identification number, and Item 24B is the place of service code.

Question 8Claims management

Which term describes the process of reviewing a claim for accuracy and completeness before it is sent to the payer?

  1. Claims reconciliation
  2. Claims adjudication
  3. Claims scrubbing Correct answer.
  4. Claims appeal

Explanation

Claims scrubbing is the pre-submission review, often automated by practice management software, that catches errors such as invalid codes or missing fields. Adjudication is the payer's decision process, and reconciliation matches payments to charges.

Question 9Claims management

A payer processes a claim and applies a contractual adjustment reducing the charge to the allowed amount. In claims management, what does this adjustment represent?

  1. The amount the patient must pay as coinsurance
  2. A penalty imposed for late filing
  3. The provider's profit margin
  4. The difference between the provider's charge and the payer's contracted allowed amount Correct answer.

Explanation

A contractual adjustment reflects the negotiated difference between the billed charge and the allowed amount under the provider's contract with the payer. The provider cannot bill the patient for this amount, unlike coinsurance or deductibles.

Question 10Claims management

A claim is denied for 'medical necessity' after review. Which action is most appropriate for the claims specialist to take first?

  1. Immediately write off the entire balance
  2. Review the documentation to determine whether clinical support exists, then decide whether to appeal Correct answer.
  3. Rebill the same claim unchanged
  4. Send the balance to collections without review

Explanation

A medical necessity denial requires evaluating whether the clinical documentation supports the service. If it does, the provider can appeal with supporting records; if not, the claim may be adjusted or the patient billed per policy.

Question 11Claims management

Which coordination of benefits (COB) rule generally applies when a patient is covered by both an employer group health plan and Medicare?

  1. Neither plan pays until the patient pays the full charge
  2. Medicare always pays primary regardless of employment status
  3. The patient chooses which plan is primary each year
  4. The employer group health plan pays primary and Medicare pays secondary Correct answer.

Explanation

When a patient has active employer group coverage, that plan is generally primary and Medicare secondary, subject to specific size-of-employer rules. Medicare Secondary Payer rules govern this ordering, not patient choice.

Question 12Claims management

A claim is submitted to the wrong payer because the front desk recorded an outdated insurance card. What is the most efficient corrective action?

  1. Verify current coverage, then submit a corrected claim to the correct payer Correct answer.
  2. Bill the patient for the full amount immediately
  3. Appeal to the wrong payer and wait for a response
  4. Resubmit the identical claim to the same payer

Explanation

The root cause is incorrect payer information, so the fix is to verify current eligibility and send a corrected claim to the proper payer. Resubmitting to the same payer or appealing to the wrong payer will not resolve the error.

Question 13Claims management

Which of the following is a common reason a claim may be denied for 'duplicate'?

  1. The patient's deductible had not been met
  2. The same service was previously billed and paid for the same date of service Correct answer.
  3. The provider was out of network
  4. The claim lacked a referring provider NPI

Explanation

Duplicate denials occur when the payer's system identifies an identical claim or service line already processed for the same patient and date. Missing referral data, deductible status, and network status produce different denial categories.

Question 14Claims management

A practice receives an 835 remittance showing a claim paid at a reduced rate with remark code N130 indicating a missing NPI. What should the claims specialist do?

  1. Bill the patient for the difference
  2. Ignore the remark code and close the claim
  3. Accept the reduced payment as final
  4. Identify the missing NPI, correct the claim, and resubmit or appeal per payer instructions Correct answer.

Explanation

Remark codes explain payment adjustments and guide corrective action. A missing NPI remark signals that corrected information should be supplied so the payer can reprocess the claim at the proper rate.

Question 15Claims management

Which statement best explains why a claim might be denied for 'non-covered service' even when the procedure code is valid?

  1. The claim was submitted on paper
  2. The procedure code is expired
  3. The patient's specific plan excludes the service from its benefit package Correct answer.
  4. The provider's NPI is invalid

Explanation

A valid code can still be non-covered if the patient's benefit plan excludes that service. Plan-specific exclusions are distinct from coding errors or credentialing issues.

Question 16Claims management

When a primary payer denies a claim but the patient has secondary coverage, what is the typical next step?

  1. Resubmit to the primary payer unchanged
  2. Discard the denial and close the account
  3. Submit the claim to the secondary payer with the primary payer's remittance attached Correct answer.
  4. Bill the patient for the full amount

Explanation

When primary coverage denies, the secondary payer may consider the claim, and the primary remittance documents the denial for the secondary. This preserves the patient's secondary benefits and avoids improper patient billing.

Question 17Claims management

A claim is denied due to timely filing. Which documentation is most useful when appealing this denial?

  1. Proof of the original submission date, such as a clearinghouse acceptance report Correct answer.
  2. The patient's insurance card copy
  3. The patient's consent form
  4. The provider's fee schedule

Explanation

Timely filing appeals require evidence that the claim was submitted within the payer's deadline. Clearinghouse acceptance reports or electronic acknowledgments establish the submission date.

Question 18Claims management

Which of the following best describes the purpose of an appeal in claims management?

  1. To request that a payer reconsider a denial or payment decision Correct answer.
  2. To submit a new patient registration
  3. To schedule follow-up appointments
  4. To verify patient eligibility

Explanation

An appeal formally asks the payer to review and reverse a denial or adjust payment based on supporting documentation and policy. It is distinct from eligibility verification and administrative scheduling.

Question 19Claims management

A claim is denied for 'invalid procedure code.' Which of the following is the most likely root cause?

  1. The code was entered with a typo or is not valid for the date of service Correct answer.
  2. The patient's deductible was not met
  3. The provider is out of network
  4. The claim was submitted electronically

Explanation

An invalid procedure code denial indicates a coding error, such as a typo or a code not effective on the date of service. Deductible status and network status do not invalidate procedure codes.

Question 20Claims management

Which of the following is the correct sequence for the claims management lifecycle?

  1. Eligibility verification, payment posting, claim submission, coding
  2. Payment posting, claim submission, coding, eligibility verification
  3. Claim submission, patient registration, payment posting, eligibility verification
  4. Patient registration and eligibility verification, coding and charge entry, claim submission, adjudication, payment posting and denial management Correct answer.

Explanation

The claims lifecycle begins with registration and eligibility, proceeds through coding and charge capture, then submission, payer adjudication, and finally payment posting and denial follow-up. Each step depends on the accuracy of the prior step.

Question 21Claims management

A provider's claim is denied because the service required prior authorization that was never obtained. Which action is most appropriate?

  1. Resubmit the same claim without changes
  2. Write off the balance without review
  3. Review the payer's authorization requirements and determine whether a retro-authorization or appeal is possible Correct answer.
  4. Bill the patient for the full charge immediately

Explanation

Authorization denials may sometimes be resolved through retro-authorization or appeal if the payer permits. The specialist should check payer policy before shifting liability to the patient.

Question 22Claims management

A practice notices a pattern of denials for a specific procedure code across multiple payers. Which approach is most appropriate for addressing this trend?

  1. Stop billing the code entirely
  2. Conduct a root-cause analysis of coding, documentation, and payer policies for that code Correct answer.
  3. Appeal each denial individually without reviewing the pattern
  4. Bill patients for all denials of that code

Explanation

A pattern of denials across payers suggests a systemic issue such as coding, documentation, or policy mismatch. Root-cause analysis identifies the underlying problem and prevents recurrence, which is more effective than case-by-case appeals.

Question 23Claims management

In the CMS-1500 form, Item 24E contains the diagnosis pointer. What is the maximum number of diagnosis codes that can be referenced in a single pointer field?

  1. Twelve
  2. Four Correct answer.
  3. Two
  4. Six

Explanation

Item 24E allows up to four diagnosis pointer letters (A through D) per service line, corresponding to the first four diagnosis codes in Item 21. Additional diagnoses cannot be referenced on that line.

Question 24Claims management

A payer's remittance shows a denial with a CARC indicating the patient is not covered by this payer. Which follow-up step is most consistent with proper claims management?

  1. Write off the balance as a contractual adjustment
  2. Verify eligibility and coverage dates, then bill the correct payer or the patient per policy Correct answer.
  3. Resubmit the identical claim to the same payer
  4. Appeal the denial to the same payer without new information

Explanation

A 'not covered' CARC indicates a coverage mismatch, so the specialist should verify eligibility and coverage dates and route the claim to the correct payer. Contractual adjustments apply only to contracted write-offs, not to coverage errors.

Question 25Claims management

A practice wants to reduce denials related to patient demographic errors. Which control is most effective?

  1. Increase the number of appeals filed each month
  2. Implement front-end eligibility and demographic verification with real-time editing before claim submission Correct answer.
  3. Reduce the number of payers billed
  4. Submit claims on paper instead of electronically

Explanation

Most demographic denials originate at registration, so real-time verification and front-end editing catch errors before the claim is submitted. Prevention at the front end is more efficient than resolving denials after adjudication.

Question 26Claims management

A claim is rejected at the clearinghouse with an error indicating the insured's identification number is invalid. Which action should the claims specialist take first?

  1. Verify the member ID against the payer's eligibility response and correct the claim Correct answer.
  2. Bill the patient for the full charge immediately
  3. Write off the balance as uncollectible
  4. Resubmit the identical claim to see if the rejection clears

Explanation

A front-end rejection for an invalid member ID means the payer could not match the claim to a member record, so the data must be verified before resubmission. Confirming eligibility and correcting the ID addresses the root cause and prevents repeat rejections. Resubmitting unchanged data will fail again and may create duplicate submission issues.

Question 27Claims management

Which CMS-1500 field is used to report the NPI of the provider who actually rendered the service?

  1. Item 24J Correct answer.
  2. Item 32
  3. Item 33
  4. Item 17

Explanation

Item 24J carries the rendering provider's NPI in the service line, linking each procedure to the provider who performed it. Item 33 holds the billing provider NPI and information, and Item 32 is the service facility location. Reporting the rendering NPI in the wrong field can cause denials for provider mismatch.

Question 28Claims management

A payer returns an 835 remittance with a claim adjustment reason code indicating the charge exceeds the fee schedule. What does this adjustment represent in claims management?

  1. A contractual adjustment the provider must accept Correct answer.
  2. A patient responsibility balance
  3. A deductible applied to the claim
  4. A refund owed to the payer

Explanation

When a participating provider's charge exceeds the allowed amount, the difference is written off as a contractual adjustment under the payer agreement. It is not billed to the patient and is not a refund. The provider's contractual obligation is to accept the allowed amount as payment in full.

Question 29Claims management

A claim is denied because the patient's coverage had already terminated on the date of service. Which source should the claims specialist check to confirm the termination date?

  1. The payer's eligibility verification response for the date of service Correct answer.
  2. The provider's credentialing file
  3. The patient's signed financial policy
  4. The practice's fee schedule

Explanation

Eligibility verification confirms whether coverage was active on the specific date of service and shows the termination date. A denial for terminated coverage can often be resolved or converted to patient responsibility once eligibility is confirmed. Other documents do not establish coverage status.

Question 30Claims management

Which document typically accompanies a claim when a payer requires proof that a secondary payer's coverage exists before processing?

  1. The practice's business associate agreement
  2. The provider's W-9 form
  3. An explanation of benefits from the primary payer Correct answer.
  4. A copy of the patient's driver's license

Explanation

Secondary payers generally require the primary payer's explanation of benefits to confirm what was paid, denied, or applied to patient responsibility. The EOB establishes the order of benefits and the remaining balance. Other documents do not demonstrate primary coverage or payment.

Question 31Claims management

What is the purpose of a claim scrubber in the revenue cycle?

  1. To calculate the patient's coinsurance amount
  2. To detect data errors and payer rule violations before transmission Correct answer.
  3. To archive paid claims for the retention period
  4. To post payments to the patient ledger

Explanation

A claim scrubber applies edits and payer-specific rules to catch missing, invalid, or inconsistent data before the claim leaves the practice. Catching these errors early reduces front-end rejections and rework. It does not post payments or manage records retention.

Question 32Claims management

A payer's remittance advice lists a claim adjustment reason code indicating the service is not covered because it is considered routine. What is the appropriate next step for the claims specialist?

  1. Report the payer to the state insurance department
  2. Resubmit the claim with a different diagnosis code
  3. Appeal the denial as a coding error
  4. Transfer the balance to patient responsibility according to the practice's financial policy Correct answer.

Explanation

A routine or non-covered determination means the plan does not include the service as a covered benefit, so the balance generally shifts to the patient unless a valid appeal basis exists. The practice should follow its financial policy and any required advance beneficiary notice. Changing diagnosis codes to force coverage would be inappropriate.

Question 33Claims management

Which of the following best describes a clean claim?

  1. A claim that contains all required data elements and passes payer edits on first submission Correct answer.
  2. A claim that has been paid in full by the payer
  3. A claim that has been appealed and overturned
  4. A claim submitted after the filing deadline

Explanation

A clean claim is complete and accurate and passes front-end edits, allowing the payer to adjudicate it without requesting additional information. Clean claims reduce rejection rates and shorten payment cycles. Payment status and appeal history are separate concepts.

Question 34Claims management

A claim for a laboratory panel is denied because the individual component codes were also billed separately on the same date. Which billing concept explains this denial?

  1. Coordination of benefits
  2. Place of service mismatch
  3. Unbundling Correct answer.
  4. Global surgical package

Explanation

Unbundling occurs when components of a panel or bundled service are billed separately, which payers prohibit because the panel code already includes them. The payer denies the components to prevent duplicate payment. Correct coding requires billing the comprehensive code alone.

Question 35Claims management

A claim is denied for lack of medical necessity on a high-cost imaging study. Which documentation is most valuable to include with the appeal?

  1. The front desk's appointment reminder log
  2. The patient's insurance card copy
  3. The practice's charge master entry
  4. The ordering provider's note documenting signs, symptoms, and failed conservative treatment Correct answer.

Explanation

Medical necessity appeals succeed when clinical documentation supports the indication for the study, including symptoms, duration, and prior treatments. This evidence shows the service met the payer's coverage criteria. Administrative documents do not address clinical justification.

Question 36Claims management

A payer denies a claim with a CARC indicating the service requires prior authorization that was not on file. The practice has a valid authorization number issued before the date of service. What should the claims specialist do?

  1. Resubmit the claim with the authorization number entered in the designated field and attach supporting documentation Correct answer.
  2. Bill the patient for the full amount
  3. Submit a new claim under a different provider NPI
  4. Change the date of service to match the authorization

Explanation

When a valid authorization exists but was omitted or not matched, the claim should be corrected to include the authorization number and resubmitted with supporting documentation. This allows the payer to reprocess against the approved authorization. Altering dates or provider identifiers to obtain payment is improper.

Question 37Claims management

A practice sees a rising rate of denials for missing modifiers on bilateral procedures. Which corrective action best addresses the root cause?

  1. Add a coding edit that flags bilateral procedures lacking modifier 50 or the appropriate LT/RT modifier before submission Correct answer.
  2. Hire additional billing staff to work denials
  3. Stop performing bilateral procedures
  4. Increase the practice's charges to offset denials

Explanation

Root-cause correction means preventing the error before submission rather than reworking denials afterward. A pre-submission edit requiring the correct bilateral modifier catches the defect at the source. Adding staff to work denials treats the symptom and increases cost.

Question 38Claims management

Which element of the CMS-1500 identifies whether the patient's condition is related to an employment injury, auto accident, or other accident?

  1. Item 10a-10c, the condition related to employment or accident boxes Correct answer.
  2. Item 28, the total charge
  3. Item 25, the federal tax ID
  4. Item 21, the diagnosis codes

Explanation

Items 10a through 10c indicate whether the service is related to employment, an auto accident, or another accident, along with the state. This information helps payers determine coordination of benefits and liability. Diagnosis codes and financial fields do not capture accident-relatedness.

Question 39Claims management

A payer's 835 remittance shows a claim paid with a remark code indicating the patient's deductible was applied. How should the claims specialist record this?

  1. As a duplicate payment to be refunded
  2. As a contractual adjustment
  3. As a provider write-off
  4. As patient responsibility in the accounts receivable Correct answer.

Explanation

Amounts applied to a deductible remain the patient's financial responsibility and should be moved to patient accounts receivable for billing. They are not write-offs because the practice is still entitled to collect them. Contractual adjustments apply only to the difference between charge and allowed amount.

Question 40Claims management

A claim is rejected because the diagnosis code reported is no longer valid for the date of service. What is the most likely cause?

  1. The place of service code was omitted
  2. The provider's NPI was entered incorrectly
  3. The diagnosis code was retired or replaced in the current code set Correct answer.
  4. The patient's insurance changed mid-year

Explanation

Diagnosis code sets are updated annually, and codes can be deleted or replaced. Using a retired code for a date of service after its deletion causes rejection. The fix is to verify the code's validity for that date and correct the claim.

Question 41Claims management

Under the HIPAA standard transactions rule, which format is used for electronic claim submission?

  1. ANSI ASC X12N 837P Correct answer.
  2. ANSI ASC X12N 270
  3. ANSI ASC X12N 276
  4. ANSI ASC X12N 835

Explanation

The 837P is the HIPAA-adopted X12 standard for professional health care claims. The 835 is the remittance advice, the 270/271 handles eligibility inquiry and response, and the 276/277 handles claim status. Using the wrong transaction type prevents proper processing.

Question 42Claims management

A claim is denied as a duplicate of a previously paid claim. The practice confirms the earlier claim was for a different date of service but identical charges. What is the most likely explanation?

  1. The payer matched the claims because the date of service was entered incorrectly on one claim Correct answer.
  2. The provider is out of network
  3. The procedure code is not covered
  4. The patient has two insurance plans

Explanation

Duplicate denials often result from claims matching on key data such as date of service, provider, patient, and charges. If one claim carried an incorrect date, the payer's system may have treated them as the same service. Reviewing both claims for data accuracy resolves the issue.

Question 43Claims management

A claim is denied for timely filing. Which documentation best supports an appeal?

  1. The original clearinghouse acceptance report showing the claim was submitted before the deadline Correct answer.
  2. The patient's signed consent form
  3. The practice's employee handbook
  4. The provider's fee schedule

Explanation

Timely filing appeals require proof that the claim was submitted within the payer's deadline. A clearinghouse acceptance report with a date and time stamp provides that evidence. If the original submission was late, the practice should check whether a payer-approved exception applies.

Question 44Claims management

A practice wants to reduce denials caused by incorrect coordination of benefits order. Which workflow control is most effective?

  1. Increasing the number of claims submitted per day
  2. Asking patients at each visit whether their coverage has changed and updating the insurance record Correct answer.
  3. Reducing the number of payers the practice contracts with
  4. Outsourcing all appeals to a collection agency

Explanation

COB errors usually stem from outdated or incomplete coverage information at the front end. Verifying and updating insurance details at every visit ensures claims go to the correct primary payer first. Volume increases and outsourcing do not correct the underlying data.

Question 45Claims management

A payer issues a denial stating the service was provided by a provider not credentialed with that plan. What is the most appropriate first step?

  1. Appeal the denial without additional documentation
  2. Resubmit the claim under a credentialed partner's NPI
  3. Bill the patient for the entire charge
  4. Verify the rendering provider's enrollment status and effective date with the payer Correct answer.

Explanation

A provider-not-credentialed denial requires confirming whether the rendering provider was enrolled and effective on the date of service. If enrollment was pending or the NPI was reported incorrectly, the claim can be corrected or the enrollment issue resolved. Billing under another provider's NPI is improper.

Question 46Claims management

A claim includes a modifier that bypasses a payer's National Correct Coding Initiative edit. What should the claims specialist confirm before using such a modifier?

  1. That the charge exceeds the payer's fee schedule
  2. That the patient has secondary insurance
  3. That the documentation supports the services as distinct and separately reportable Correct answer.
  4. That the claim will be submitted on paper

Explanation

Override modifiers should only be used when clinical documentation shows the services were distinct and separately reportable. Using them routinely to bypass edits can trigger audits and recoupment. Secondary coverage and charge amounts are unrelated to edit overrides.

Question 47Claims management

A payer recoups payment on a previously paid claim and issues a demand letter citing a post-payment audit finding. Which response best protects the practice?

  1. Review the audit findings, compare them to the documentation, and submit a formal appeal with supporting records within the stated timeframe Correct answer.
  2. Refund the amount immediately without review
  3. Resubmit the original claim unchanged
  4. Ignore the letter until the payer sends a second notice

Explanation

Post-payment audits require the practice to compare the payer's findings against the clinical documentation and respond through the appeal process within the deadline. Some findings may be valid while others may be rebutted with records. Immediate refunds without review or ignoring notices can forfeit appeal rights.

Question 48Claims management

A practice discovers that claims for one provider are consistently denied for place of service mismatch between the professional claim and the facility claim. Which analysis is most useful to identify the root cause?

  1. Compare the provider's salary to peers
  2. Check the practice's marketing budget
  3. Review the patient's payment history
  4. Compare the place of service codes billed on the professional claims against the facility's UB-04 for the same dates Correct answer.

Explanation

Place of service mismatches are identified by comparing the POS reported on the CMS-1500 with the facility bill for the same encounter. This reveals whether the error lies in the professional claim, the facility claim, or both. Financial and administrative comparisons do not address the coding discrepancy.

Question 49Claims management

A payer's policy states that claims for a specific service must include a supporting documentation attachment submitted through the payer's portal. A paper claim was submitted without it and denied. What is the best corrective action?

  1. Change the procedure code to one that does not require documentation
  2. Bill the patient for the denied amount
  3. Mail a duplicate paper claim
  4. Submit a corrected claim through the portal with the required documentation attached Correct answer.

Explanation

When a payer requires documentation through a specific channel, the claim must be resubmitted through that channel with the attachment to be adjudicated. Mailing another paper claim repeats the original error. Changing the procedure code to avoid documentation requirements misrepresents the service.

Question 50Claims management

A practice's denial report shows that a large share of denials are for missing or invalid prior authorization numbers on high-cost drugs. Which metric best tracks the effectiveness of a corrective action?

  1. The number of new patients seen
  2. The percentage of high-cost drug claims denied for authorization errors before and after the intervention Correct answer.
  3. The average patient wait time at check-in
  4. The total number of claims submitted per month

Explanation

Effectiveness is measured by tracking the specific denial category before and after the intervention. A decline in authorization-related denials for high-cost drugs shows the corrective action is working. Volume and scheduling metrics do not measure denial prevention.