Chapter 30 — Quiz

26 questions. Answers and explanations are in the instructor guide.

1. The appealable amount on a denied line is:

  • A. The charge
  • B. The allowed amount
  • C. The plan payment
  • D. The patient responsibility

2. Submitting a corrected claim when you meant to appeal can, at some payers:

  • A. Speed the appeal
  • B. Forfeit the appeal rights attached to the original determination
  • C. Extend the filing window
  • D. Have no effect

3. Account 10-5502's CARC 197 denial was correctly handled by:

  • A. A level-one appeal
  • B. A peer-to-peer demand
  • C. A phone call, four more documented weeks, and resubmission
  • D. External review

4. The one timely filing (CO-29) denial worth appealing is the one with:

  • A. A large dollar amount
  • B. A sympathetic patient
  • C. Proof the claim was filed on time, such as a payer acknowledgment
  • D. A signed provider attestation

5. An appeal's request should read most like:

  • A. "We respectfully request review of this claim"
  • B. "Reprocess line 1 and pay at the contracted allowed amount of \$128.40"
  • C. "Please review all claims for this patient"
  • D. "We dispute this denial in the strongest terms"

6. In the six-part letter, the standard comes before the demonstration because:

  • A. Payers require it
  • B. A reviewer who has read the rule reads your facts as evidence rather than as a story
  • C. It makes the letter longer
  • D. The facts are confidential

7. The Encounter's appeal cited exactly three documents:

  • A. The note, the CMS-1500, and the 835
  • B. The note, the NCCI Policy Manual, and the payer's own published policy
  • C. The note, the LCD, and the fee schedule
  • D. The chart, the contract, and the state statute

8. Only 10 of the appeal's 31 minutes were spent drafting, because:

  • A. The letter was short
  • B. Only the demonstration is new work; the citations live in a maintained paragraph library
  • C. The biller was experienced
  • D. The payer's portal is fast

9. "Constructing an argument" differs from "constructing a record" in that constructing an argument:

  • A. Requires a physician's signature
  • B. Uses only facts already documented, arranged so their consequence is visible
  • C. Adds an addendum to the note
  • D. Is only allowed at level two

10. A post-denial addendum asserting exactly the disputed element is dangerous because:

  • A. It is illegible
  • B. Amendments are dated and attributed, and a reviewer will discount the note — or refer the file
  • C. It restarts timely filing
  • D. It requires the patient's consent

11. Commercial appeal windows run from:

  • A. The date of service
  • B. The date the claim was filed
  • C. The date of the determination being appealed
  • D. The end of the calendar year

12. For a self-funded plan, the appeal framework is:

  • A. State insurance law
  • B. ERISA and the DOL claims-procedure regulation
  • C. The state external review statute
  • D. The Medicare five levels

13. Under ERISA, appeal rights belong to:

  • A. The provider
  • B. The state
  • C. The plan participant — the provider typically acts as authorized representative
  • D. The TPA

14. The five levels of Medicare appeal, in order, are:

  • A. Reconsideration, redetermination, ALJ, Council, judicial review
  • B. Redetermination, reconsideration, ALJ, Council, judicial review
  • C. Redetermination, ALJ, reconsideration, Council, judicial review
  • D. Peer-to-peer, redetermination, reconsideration, ALJ, judicial review

15. The redetermination is decided by:

  • A. The QIC
  • B. The MAC, by staff not involved in the initial determination
  • C. OMHA
  • D. The Appeals Council

16. The filing windows for levels 1 and 2 are, respectively:

  • A. 60 and 60 days
  • B. 120 and 180 days
  • C. 180 and 120 days
  • D. 90 and 90 days

17. An amount-in-controversy requirement first appears at:

  • A. Redetermination
  • B. Reconsideration
  • C. The ALJ hearing
  • D. Judicial review only

18. The evidence rule at reconsideration says:

  • A. Evidence may be added at any level
  • B. Present all evidence by the reconsideration; later evidence may be excluded absent good cause
  • C. Only the beneficiary may submit evidence
  • D. The QIC gathers its own evidence

19. "Escalation" in the Medicare ladder means:

  • A. Complaining to the MAC's supervisor
  • B. Moving the appeal to the next level when the current level misses its decision timeframe
  • C. Adding interest to the claim
  • D. Filing in state court

20. The peer-to-peer call should be made by:

  • A. The biller
  • B. The practice manager
  • C. The treating physician
  • D. The payer's provider-relations representative

21. The prep-sheet item practices most often skip is:

  • A. The reference number
  • B. The gap, named — what the reviewer will say is missing
  • C. The callback number
  • D. The date of service

22. External review by an IRO decides questions of:

  • A. Contract pricing
  • B. Timely filing
  • C. Medical judgment — necessity, level of care, experimental status
  • D. Claim formatting

23. The external review request window is generally:

  • A. 30 days
  • B. 60 days
  • C. Four months from the final internal adverse determination
  • D. One year

24. When a Medicare Advantage plan upholds its own denial at the plan level, the case is:

  • A. Closed
  • B. Forwarded automatically to an independent review entity
  • C. Sent to the state insurance department
  • D. Converted to a Part B appeal

25. The appeal log's two calendars are:

  • A. Fiscal and calendar year
  • B. Your filing deadlines and the payer's decision deadlines
  • C. The provider's and the patient's
  • D. Submission and posting

26. An appeal is resolved when:

  • A. The letter is mailed
  • B. The payer confirms receipt
  • C. The favorable decision letter arrives
  • D. The money posts on a remittance and the outcome flows back to the denial log