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1. Which of these is an example of a reason to dispute a payors determination and have it reviewed?
A
Both B & C
B
Payor processes/denies a charge in error.
C
Payor under paid on a code per the fee schedule.
2. What is the 1st step to determining if an appeal is necessary?
A
Make your case as to why the denial was in error.
B
Learn the timely filing guidelines for the appeal with that insurance.
C
Verify precisely why the insurance denied the claim.
3. What are the 3 steps in the Appeals process?
A
Redetermination, Reconsideration, Review by IRO ( appeal)
B
Appeal, 2nd level appeal, IRE review
C
Call the payor, send an appeal, write off claim.
4. T/F- Whenever possible, upload/complete appeals online.
A
T
B
F
C
N/A
5. What is a redetermination?
A
An independent review of the administrative record.
B
An independent re-examination of an initial claim determination.
C
An appeal to an outside organization, IRO.
6. How often should you go past a 2nd level of appeal for a claim?
A
As many times as it takes to get claims paid.
B
Almost never.
C
50% of the time, depending on which payor it is.
7. When sending information to the payor,
A
You should send the minimum amount of info needed to support your case.
B
Send all info you can find, to overwhelm the payor so they will go ahead and pay the claim.
C
be sure to include Steve's email so the payor can reach out to him.
8. If at any point you doubt yourself, that you may not be fully understanding the denial you are seeing,
A
Adjust and move on to the next claim.
B
go ahead and send an appeal with records.
C
call the payor and verify the denial and what supporting info they need from you.
9. If you are not sure where to send the forms, letters and documentation to support your case
A
Send an email to the claims dept.
B
take your best guess and the payor will make sure to forward to the correct dept.
C
call the payor.
10. Laura's advice regarding appeals states:
A
If you have tried once to appeal, reach out to coding/compliance.
B
When in doubt, send it out.
C
Appeals are just a formality, after your 1st appeal is denied, adjust it off and move on.
11. T/F- You should document everything you send out to a payer for review.
A
T
B
F
C
N/A
12. All info sent out to a payor should be
A
Added to the pt's chart.
B
put in the TEAMS files
C
scanned into Onbase.
13. It is important that your appeal letter be
A
neat, professional, legible, error-free, contain all info needed
B
as vague as possible to confuse the payor so they will just pay the claim.
C
Always sent by mail so there are hard copies available.
14. Do you need to send your appeal to your supervisor for review before you send it to the payor?
A
It's optional.
B
Yes.
C
No.
15. What are the 3 parts of an appeal letter as described in this session?
A
Opening statements, Cross examination, Closing statements
B
Heading, Salutation, Post-Script
C
Claim- Identifying info, Contact info, Sound reasoning.