AAPC Denial Management & Appeals 1 — Questions and Answers
Question 1: Which denial reason code indicates that a claim was rejected because the service is not covered under the patient's plan?
- CO-4
- CO-97
- CO-96 (Correct answer)
- CO-45
Correct answer: CO-96
CO-96 is the CARC (Claim Adjustment Reason Code) used when a service is not covered under the patient's plan or benefit package.
Question 2: What is the first step a biller should take when a claim is denied due to 'coordination of benefits' (COB)?
- Write off the balance immediately
- Verify primary and secondary insurance information and resubmit in correct order (Correct answer)
- Send the claim to the patient for payment
- Appeal the denial to the state insurance board
Correct answer: Verify primary and secondary insurance information and resubmit in correct order
When a claim is denied for COB issues, the biller must verify which payer is primary and which is secondary, then resubmit claims in the correct order.
Question 3: A claim is denied with reason code CO-29. What does this mean?
- Duplicate claim submitted
- The time limit for filing has expired (Correct answer)
- Non-covered service
- Authorization was not obtained
Correct answer: The time limit for filing has expired
CO-29 indicates the claim was denied because it was filed after the payer's timely filing deadline.
Question 4: Which document is most important to include when appealing a claim denied for 'medical necessity'?
- Explanation of Benefits (EOB)
- Patient's driver's license
- Physician's clinical documentation and supporting medical records (Correct answer)
- Patient's signed financial agreement
Correct answer: Physician's clinical documentation and supporting medical records
Medical necessity appeals require clinical documentation such as physician notes, test results, and treatment plans to justify that the service was medically necessary.
Question 5: What is a 'timely filing' denial, and what is the typical remedy?
- A denial because the patient has two insurances; remedy is COB resolution
- A denial because the claim was submitted after the payer's deadline; remedy is providing proof of timely submission (Correct answer)
- A denial for duplicate billing; remedy is voiding the duplicate
- A denial for missing modifiers; remedy is resubmitting with the correct modifier
Correct answer: A denial because the claim was submitted after the payer's deadline; remedy is providing proof of timely submission
Timely filing denials occur when claims are submitted past the payer's deadline; billers can appeal by providing proof (e.g., electronic submission reports) that the claim was sent within the allowed window.
Question 6: Which of the following best describes a 'soft denial'?
- A final denial that cannot be appealed
- A denial that can be corrected and resubmitted without a formal appeal (Correct answer)
- A denial issued by Medicare only
- A denial that requires an attorney to resolve
Correct answer: A denial that can be corrected and resubmitted without a formal appeal
A soft denial is a temporary or correctable denial that can be resolved by submitting additional information or correcting errors without going through a formal appeal process.
Question 7: When a payer denies a claim stating 'duplicate claim,' what should the biller do first?
- Immediately bill the patient for the full amount
- Verify whether the original claim was already paid or is still pending before resubmitting (Correct answer)
- Submit a corrected claim with a different date of service
- File a complaint with CMS
Correct answer: Verify whether the original claim was already paid or is still pending before resubmitting
Before resubmitting, the biller should check the payer's records or remittance advice to confirm whether the original claim was paid, pending, or truly a duplicate error.
