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HIM2135 Revenue Cycle Management Module 6 Revenue Cycle Fiscal Accountability Appeals Process Student Worksheet Assignment Instructions: Evaluate the Denial Scenarios and corresponding Remittance Advice. Determine if the denial is a Technical or Clinical Denial. Specify the appropriate response if the denial is “soft” and can be appealed or “hard” and has to be accepted. Response options are: Soft/Appeal or Hard/Accept Justify your decisions by indicating the rationale for your decision using the rationale codes in the Rationale Options section below the table with the Denial Scenarios. Review definitions for denials under Module 6 Lesson Content “Denials Appeals Process”. Denial Scenarios Technical or Clinical Denial Soft/Appeal Hard/Accept Rationale (Choose Code from table below) 1-An outdated diagnosis or procedure code was submitted on the claim. Remittance Advice: States invalid codes submitted on the claim. 2-The service provided is allowable per patient’s benefit coverage once every 3 years. Patient has previously met their allowance for the time period. Remittance Advice: States the service performed exceeds coverage limits allowed for the patient. 3-The Insurance Carrier determined the procedure performed to be experimental. The claim is missing the appropriate CPT code (unlisted procedure) and there is no documentation to support Medical Necessity for the procedure. Remittance Advice: States the procedure performed is experimental and there is no CPT Code for an unlisted procedure or supporting documentation submitted with the claim. 4-At the time of patient registration, the scheduled services did not meet Medical Necessity. An ABN was presented to the patient during registration and was completed and signed by the patient. The patient indicated on the form they wished for the services be performed and requested that Medicare be billed for an official decision on payment. Subsequently, coding of the documentation in the patient’s chart at discharge determined that Medical Necessity was met. Remittance Advice: States the claim is denied as an ABN was not completed prior to the provision of services. The facility has a copy of dated, timed, and signed ABN is on file. 5-Surgical charges were submitted on a claim without any ICD-10 Procedure Codes corresponding to the charges. Remittance Advice: States that there are no procedure codes to support the charges submitted on the claim. Following investigation by coding and clinical services, procedure codes were added to the account. 6-The claim for services contains charges and codes for a procedure performed that is not a covered benefit for the patient. Remittance Advice: Claim denied due to non-coverage for the patient. 7-A claim has been submitted for services rendered. The claim has been denied. Remittance Advice: States that there is no supporting documentation for the services performed. Upon review of the patient’s record, there is no additional information available. 8-The service provided for the patient is paid at 80% of charges in accordance with the patient’s covered benefits. Remittance Advice: Indicates per patient’s benefit policy, the service is only covered at 80%. Partial payment received by the facility. 9-The claim was filed without the insurance carrier’s policy number on the claim form. Remittance Advice: States the claim is missing the insurance carrier’s policy number to determine if the patient has covered benefits with the carrier. 10-An expensive drug was administered in the hospital Emergency Room for the patient’s convenience. Insurance coverage is approved only when performed in the physician’s office or outpatient clinic setting. Remittance Advice: States that the hospital related charges are denied by the payer as coverage is not allowed in an Emergency Room or other hospital setting. 11-The patient presented for suture removed in the local Emergency Room several days following a procedure performed in the physician’s office. The Emergency Room billed for the suture removal. Remittance Advice: States suture removal is part of the surgical package and cannot be billed separately. 12-The patient has Medicare coverage and Commercial Insurance coverage through his spouse’s employer. Medicare is a secondary payer with the Commercial Insurance primary. Medicare was billed as primary for the services rendered to the patient. Remittance Advice: States that the claim is denied as Medicare is not the primary insurance. Rationale Options Rationale Rationale Code to Enter in Table Above The documentation has been reviewed and additional diagnosis and/or procedure codes are appended to the account based on the documentation available in the patient’s medical record and consultation with clinical services. R1 A new (experimental) procedure requiring an “unlisted procedure” code did not include proof of medical necessity with the original claim. Supporting documentation is available from the provider along with the “Unlisted CPT Procedure Code” R2 Policy number was not included on the claim but is available in the patient’s account information in the EHR and is now entered on the claim. R3 Invalid (outdated) codes were submitted due to a coding error. The correct codes have been now been entered on the account. R4 Additional documentation is available in the patient’s chart following services/treatment to support medical necessity e.g. preauthorization, ABN, clinical documentation etc R5 The facility is requesting payment for services that are not a covered benefit for the patient or allowable coverage limits have been met e.g. annually every 12 months. R6 The case has been reviewed and there is no documentation to indicate the charged services were performed for the patient. Charges will be removed. R7 The patient’s covered benefits indicate the service performed is only payable at a reduced rate (for example, 80%). Partial payment at the 80% rate has been paid to the facility. The facility will need to determine if they are allowed to bill the patient for the remainder of the charges or write-off the remaining balance. R8 Procedures performed for patient or provider convenience are not covered by policy. Services only covered in an outpatient/clinic setting and not covered for an Emergency Room or Hospital setting. R9 Services are included in surgical package and may not be unbundled to be billed separately. R10 Medicare as the secondary payer requires the claim to be submitted to the primary carrier first. R11

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