Certified Medical Assistant (CMA AAMA)Administrative: Billing, Coding and SchedulingEasy
A medical assistant is reviewing a claim denial where the insurance company states the patient's coverage was terminated prior to the date of service. Which of the following is the most appropriate initial action?
- AContact the patient to verify current insurance information.
- BWrite off the balance as uncollectible.
- CAppeal the denial to the insurance company immediately.
- DResubmit the claim with a different diagnosis code.
Show answer & explanationAnswer & explanation
Correct answer: A. Contact the patient to verify current insurance information.
When a claim is denied due to terminated coverage, the first step is to verify the patient's insurance status directly with the patient. This helps determine if new insurance exists or if the termination date was incorrect.
Why the other options are wrong
- B. Writing off the balance is premature; there may be valid insurance coverage or a billing error to correct.
- C. Appealing the denial without clarifying the coverage issue first is inefficient and unlikely to be successful.
- D. Changing the diagnosis code without verifying coverage would not resolve a terminated coverage denial.
Claim Denial Resolution
The process of investigating and resolving reasons for claim rejections or denials by insurance payers.
- Always identify the specific reason for denial.
- Prioritize verification of patient demographics and insurance information.
- Follow up with the patient or payer as needed.
Memory trick: Don't deny the denial, verify and clarify!