If an Insurance Carrier Does NOT Reconsider a Downcoded Claim

question 19

Multiple Choice

If an insurance carrier does NOT reconsider a downcoded claim that has been appealed, the medical office specialist can:

• A) request assistance from the state insurance commissioner.
• B) file a complaint with the Department of Health and Human Services (DHHS).
• C) file a complaint with the Centers for Medicare and Medicaid Services (CMS).
• D) bill the patient for the remaining balance.

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Definitions:

Certificate Of Waiver

A document that grants permission to a healthcare facility to perform certain tests or procedures that are typically regulated, without adhering to the standard oversight or requirements.

Medicare

A federal program for providing health care coverage for individuals over the age of 65 or those who are disabled.

Medicaid

A joint funding program by federal and state governments (excluding Arizona) for the medical care of low-income patients on public assistance.

Moderately Complex Tests

Laboratory tests that are not considered waived under CLIA standards and require a higher level of oversight, including specific quality control and personnel qualifications.