Question
Answered step-by-step
Asked by duniahirsi
HIM1103-Mod-05-Rejection-and-Denial-Scenarios Answers? Module 05 Assignment – Rejection and Denial Scenarios
11.
Scenario 11: The patient was scheduled to deliver by C-Section at 40 weeks according to her anticipated
due date. The provider was planning to be on vacation at the time of the scheduled due date. To
accommodate the provider’s vacation plans, the C-Section was rescheduled for 1 week earlier. The payer
refused to pay stating the procedure was performed for the provider’s convenience. The case will be
investigated to determine if there is justification for the change in schedule for the C-Section.
Remittance Advice:
(Delete all but one.)
Facility Response:
(Delete all but one.)
Responsible Party/Department:
(Delete any that do not fit the scenario.)
ï‚·
Denial
ï‚·
Rejection
ï‚·
Partial Payment
ï‚·
Accept
ï‚·
Resubmit
ï‚·
Appeal
ï‚·
Coding
ï‚·
Patient Accounts
ï‚·
Billing
ï‚·
Provider (Clinical Services)
ï‚·
Utilization Management
ï‚·
Clinical Documentation Specialist (CDS)
ï‚·
Patient Access/Admissions
12.
Scenario 12: Medicare has paid a lower amount than expected stating that the patient’s extended length
of stay was not warranted based on the diagnoses and procedures submitted on the inpatient account.
The discharge summary only stated a principal diagnosis and no secondary diagnoses indicating there
were complications or other co-morbid conditions. The case will be reviewed for additional
documentation.
Remittance Advice:
(Delete all but one.)
Facility Response:
(Delete all but one.)
Responsible Party/Department:
(Delete any that do not fit the scenario.)
ï‚·
Denial
ï‚·
Rejection
ï‚·
Partial Payment
ï‚·
Accept
ï‚·
Resubmit
ï‚·
Appeal
ï‚·
Coding
ï‚·
Patient Accounts
ï‚·
Billing
ï‚·
Provider (Clinical Services)
ï‚·
Utilization Management
ï‚·
Clinical Documentation Specialist (CDS)
ï‚·
Patient Access/Admissions
13.
Scenario 13: A Medicare patient presented for diagnostic testing at the hospital. The diagnosis submitted
for the test did not meet Medical Necessity. The patient was presented with an Advance Beneficiary
Notice and decided to proceed with the test stating that Medicare should still be billed. Medicare did not
pay for the test and the patient will now be billed.
Remittance Advice:
(Delete all but one.)
Facility Response:
(Delete all but one.)
Responsible Party/Department:
(Delete any that do not fit the scenario.)
ï‚·
Denial
ï‚·
Rejection
ï‚·
Partial Payment
ï‚·
Accept
ï‚·
Resubmit
ï‚·
Appeal
ï‚·
Coding
ï‚·
Patient Accounts
ï‚·
Billing
ï‚·
Provider (Clinical Services)
ï‚·
Utilization Management
ï‚·
Clinical Documentation Specialist (CDS)
ï‚·
Patient Access/Admissions
Page
7
of
8
14.
Scenario 14: A Remittance Advice was received for an outpatient claim for $3,600. The patient’s coverage
allowed for the test to be performed once in a 12-month period. The patient had the test performed 10
months ago. The claim will be written off.
Remittance Advice:
(Delete all but one.)
Facility Response:
(Delete all but one.)
Responsible Party/Department:
(Delete any that do not fit the scenario.)
ï‚·
Denial
ï‚·
Rejection
ï‚·
Partial Payment
ï‚·
Accept
ï‚·
Resubmit
ï‚·
Appeal
ï‚·
Coding
ï‚·
Patient Accounts
ï‚·
Billing
ï‚·
Provider (Clinical Services)
ï‚·
Utilization Management
ï‚·
Clinical Documentation Specialist (CDS)
ï‚·
Patient Access/Admissions
15.
Scenario 15: The facility received a notice from the payer that the claim they received was missing the
patient’s insurance policy number. The claim was reviewed, and the policy number provided for the
claim.
Remittance Advice:
(Delete all but one.)
Facility Response:
(Delete all but one.)
Responsible Party/Department:
(Delete any that do not fit the scenario.)
ï‚·
Denial
ï‚·
Rejection
ï‚·
Partial Payment
ï‚·
Accept
ï‚·
Resubmit
ï‚·
Appeal
ï‚·
Coding
ï‚·
Patient Accounts
ï‚·
Billing
ï‚·
Provider (Clinical Services)
ï‚·
Utilization Management
ï‚·
Clinical Documentation Specialist (CDS)
ï‚·
Patient Access/Admissions
SCIENCE
HEALTH SCIENCE
NURSING
