RCM 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.

Credentialing verifies the provider’s qualifications, contracting establishes the business and participation terms with the payer, and enrollment establishes the provider or organ…

I would first confirm the actual payer effective date and whether the provider, group, and location were correctly enrolled. For pre-effective-date services, I would review the pa…

Retroactive enrollment is a payer-approved enrollment effective date that reaches back before the final approval or processing date. It may be requested when payer rules allow and…

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…

Credentialing and enrollment problems can create unpaid or denied claims when the payer does not recognize the provider, group, location, or effective date. These balances age in…

Enrollment problems can lead to denials such as provider not enrolled, provider not eligible for the date of service, invalid provider identifier, provider not affiliated with the…