Denial Management & Appeals Interview Questions

A duplicate claim denial occurs when the payer believes the same or substantially similar service has already been submitted or processed.

A medical necessity denial occurs when the payer determines that the billed service does not meet its coverage criteria for being reasonable, necessary, or appropriate for the pat…

I would compare the denied claim with prior claim history to determine whether it is truly duplicate, a valid repeat service, or a corrected claim that was submitted incorrectly.

A bundling denial occurs when the payer considers one billed service included in another service and therefore does not allow separate payment.

I would verify the code pair, current edit, modifier indicator, documentation, and payer policy before deciding whether the denial is correct or whether a supported modifier or ap…

An eligibility denial occurs when the payer determines that the patient was not covered, not active, or not eligible for the billed service on the date of service.

I would verify the patient's coverage for the date of service, compare payer and demographic information, review COB, and determine whether the claim needs correction, rebilling t…

A coordination of benefits denial occurs when the payer cannot process the claim correctly because the patient's primary and secondary insurance order is missing, incorrect, or no…

A provider enrollment denial occurs when the payer does not recognize the rendering or billing provider, group, location, specialty, or affiliation as properly enrolled for the se…

A non-covered service denial occurs when the payer determines that the billed service is excluded, not a covered benefit, outside policy criteria, or otherwise not payable under t…