Appeals Process Assignment Answer Key lt;Student Namegt; For each reason, indicate the appropriate action (Accept, Resubmit, or Appeal). Then,...

Appeals Process Assignment Answer Key <Student Name>

For each reason, indicate the appropriate action (Accept, Resubmit, or Appeal). Then, provide the rationale for your decision using the rationale code in the Rationale Options section below the table (for example, D1).

Reason for Denial, Rejection, or Partial Payment	Indicate One of the Following Actions: Accept Resubmit Appeal	Provide Rationale for Decision:
The wrong diagnosis or procedure code was submitted.
The service provided is only allowed once every 3 years.
The payer determined the procedure to be experimental.
The services rendered do not meet Medical Necessity.
The diagnosis or procedure code(s) were missing.
The procedure performed is not a covered benefit for the patient.
Information is missing or incomplete. No additional information is available.
The service provided is paid at only 80% of charges.
The claim was filed without the insurance carrier’s policy number on the CMS-1500 claim form.
An expensive drug was administered in the hospital setting for the patient’s convenience rather than in the provider’s office.
The patient had suture removed in the local Emergency Room following a procedure performed in the physician’s office. Suture removal is part of the surgical package.

Rationale Options

Rationale to Appeal or Resubmit
Rationale	Code to Enter in Table Above
The documentation has been reviewed and additional diagnosis/procedure codes appended to the account based on the documentation available in the patient’s medical record.	A1
A new (experimental) procedure requiring an “unlisted procedure” code did not include proof of medical necessity with the original claim. Supporting documentation is available.	B1
Policy number was not included on the claim. Policy number is located on the patient’s account information.	C1
Wrong codes submitted due to a data entry error. The correct codes have been entered.	D1
Additional documentation is available to support medical necessity for the services.	E1
Rationale to Accept Denial/Rejection/Partial Payment
The claim is requesting payment for a non-covered benefit.	A2
The case has been reviewed and there is no additional documentation to support Medical Necessity.	B2
Coverage benefits indicate the service is payable at a reduced rate (for example, 80%).	C2
This is a patient convenience item and is not covered.	D2
Included in surgical package.	E2