Denial Management & Appeals Interview Questions

A denial root cause is the underlying process, documentation, coding, eligibility, authorization, enrollment, or billing issue that actually caused the payer to deny the claim.

A Claim Adjustment Reason Code, or CARC, explains the general reason a payer adjusted, denied, or assigned responsibility on a claim or service line.

A Remittance Advice Remark Code, or RARC, provides additional information that clarifies the payer's adjustment or denial reason.

A corrected claim fixes claim data, a reconsideration asks the payer to re-review an adjudication, and an appeal is a formal challenge to a denial or payment decision under the pa…

A corrected claim is usually appropriate when the original claim contains a fixable billing error such as an incorrect code, modifier, provider, diagnosis linkage, units, demograp…

A strong appeal clearly identifies the claim, states the denial issue, explains why reconsideration is justified, includes supporting documentation, cites relevant policy when app…

Timely filing is the payer's deadline for submitting an initial claim or, in some cases, corrected claims and appeals within a defined period.

I would verify the payer's filing limit, confirm the original submission date, gather proof of timely submission or valid delay circumstances, and use the payer's reconsideration…

An authorization denial occurs when the payer determines that required prior authorization, precertification, notification, or referral requirements were not met for the billed se…

I would first determine whether authorization was actually required, whether one existed, and whether the payer allows retroactive authorization or an appeal based on emergency, m…