Medically Necessity - 1 S Learning Plan

Which scenario best represents a CO‑50 denial for lack of medical necessity?

• Submitting a claim after the filing limit has passed

• Chest X‑rays are not medically necessary for an ear infection, so the payer would deny the claim as CO‑50

• Using an outdated CPT code on the claim

• Billing a service without prior authorization

Which guideline determines whether Medicare covers a service nationwide?

• NCDs apply nationwide and specify Medicare coverage for certain services.

• Commercial Payer Policy

• Local Coverage Determination (LCD)

• Provider Billing Manual

What should be done first during pre‑call analysis for a CO‑50 denial?

• Send an appeal immediately

• Resubmit the claim without changes

• Call the insurance without reviewing documentatio

• Call the insurance without reviewing documentatio

If the coding team confirms that the diagnosis code is correct but the claim is still denied as not medically necessary, what is the next step?

• Write off the balance

• Resubmit the same claim again

• Close the claim as non‑recoverable

• If coding is correct, the next step is to send an appeal before the appeal time limit expires

Which of the following is a common reason a payer may deny a claim as CO‑50?

• The provider billed with an outdated NPI

• The patient’s insurance policy terminated after the date of service

• The claim was submitted with the wrong tax ID

• LCD/NCD guidelines determine whether a service is medically necessary. 

If the insurance representative refuses to provide coding guidance during the call, what should be done next? ( Select all, more than 1 answer)

• Send the claim again without changes

• When the rep cannot provide coding details, the next step is to follow the SOP to determine the correct action.

• Close the claim as non‑recoverable

• Request Rep to Reprocess the claim 

Which of the following must be obtained from the insurance if medical records are required?

• Provider’s credentialing status

• The patient’s premium amount

• When medical records are required, the representative must provide the mailing/fax details, attention line, and the time limit for submission

• Patient’s employer information

LCDs are created by:

• Medicare contractors

• Patients

• Hospitals

• Individual providers

If previous DOS with the same CPT/DX were paid, what should be done?

• Call and request reprocessing

• Write off the claim

• Update patient demographics

• Send an appeal

Which service is often denied as cosmetic and not medically necessary?

• Flu vaccination

• Botox for wrinkles

• Blood glucose test

• X‑ray for fracture

Tags

CCSS.RL.11-12.6