AAPC-CPB Certified Professional Biller - Set 5 - Part 3

Correct Answer: Review by someone not in the initial determination

A redetermination is an independent second look at the claim and supporting documentation. Medicare guidance requires that the individual performing it must not be the same person who made the initial determination. Option b is incorrect because that deadline governs how long a provider or supplier has to send requested documentation, and it says nothing about the reviewer's identity. Option c is incorrect because in the guidance, this limit applies to claims denied after complex prepayment, complex postpayment, or automated postpayment review, and it concerns scope, not who performs the review. Option d is incorrect because the reviewer may not make a finding of criminal or civil fraud, but that restriction concerns the outcome of the review, not who is assigned.

Correct Answer: All parties to the appeal

MAC guidance requires the MAC to issue a notice of dismissal in writing, or transmit it as permitted, to all parties to the appeal, including the requesting party's representative. The notice also states the reason for the dismissal. Option a is incorrect because the QIC reviews a dismissal only when a party asks for it, so it is not the required recipient of the dismissal notice. Option c is incorrect because this names just two recipients, but the guidance directs the notice to all parties to the appeal, which can include others. Option d is incorrect because the notice goes beyond the party who filed the request; it also reaches that party's representative and every other party to the appeal.

Correct Answer: Vacates the dismissal and remands the case

When the QIC finds the contractor incorrectly dismissed a redetermination request, it vacates the dismissal and remands the case to the contractor, which is then required to issue a new redetermination decision. Option a is incorrect because workload counting applies to the contractor, whose new decision after a remand is counted in CROWD as a redetermination, not a reopening. Option b is incorrect because the QIC does not decide the redetermination; the contractor must issue the new redetermination decision on any case the QIC remands. Option d is incorrect because a second dismissal notice is not part of the process; an incorrect dismissal is vacated and the contractor must redetermine the request.

Correct Answer: Oldest documents on the bottom, most recent on top

The MAC separates procedural and medical documents and builds the case file from the bottom up, with the oldest set of documents on the bottom and the most recent set at the top. Option a is incorrect because alphabetical order applies to large cases with multiple beneficiary files, where files are organized by individual beneficiary, not by provider. Option c is incorrect because reverses the required order; the MAC builds the file from the bottom up, starting with the oldest set of documents at the base. Option d is incorrect because conflicts with the guidance, which states that the MAC does not place the medical documentation on the bottom of the file.

Correct Answer: QIC

Under the Medicare manual, effectuation of a reconsideration is triggered only by the QIC's formal decision and Reconsideration Effectuation Notice. Correspondence from any party does not prompt the MAC to adjust the claim and issue payment. Option a is incorrect because it is the fourth level of appeal, reviewing ALJ or attorney adjudicator decisions, and does not issue the reconsideration effectuation notice. Option b is incorrect because the MAC does not effectuate based on correspondence from any party to the reconsideration, so a request from the appellant does not trigger action. Option c is incorrect because it provides judicial review at the fifth level and only rarely issues an order that requires a MAC to effectuate.

Correct Answer: Statutory authority for fraud and abuse provisions

The quoted sections of the Act supply the civil and criminal violation provisions that protect Medicare from fraud and abuse. They are the statutory authority for the fraud and abuse provisions, and the manual cites them as that authority. Option a is incorrect because down-coding when services were not furnished as billed is a MAC action described in manual guidance; the quoted sections supply civil and criminal violation provisions instead. Option b is incorrect because representative appointment is addressed in separate appeals provisions covering duration, correspondence and death of the beneficiary, and these Act sections are not cited for that purpose. Option d is incorrect because case file handling is set by Medicare manual instructions to the MAC and UPIC, not by the Act sections quoted in the excerpt.

Correct Answer: Reduce payment and forward the suspected violation to the UPIC

A reviewer who suspects a violation decides only the coverage or payment issues. The reviewer may deny or reduce payment for services not rendered as billed and must forward information on the potential violation to the UPIC. Option b is incorrect because the MAC lacks authority to suspend redeterminations at OIG or DOJ request without approval and direction from the CMS central office. Option c is incorrect because the manual states a reviewer cannot make a determination of civil or criminal fraud; the decision is limited to coverage or payment issues. Option d is incorrect because appeal rights after a not-furnished or not-furnished-as-billed determination remain the same as for any other unfavorable decision, so they cannot be removed.

Correct Answer: Written authorization signed by the beneficiary

Under the Medicare manual's disclosure provisions, the beneficiary or the third party gives the MAC written authorization. It must carry the beneficiary's signature and explain the type of information the beneficiary agrees to release. Option a is incorrect because the UPIC receives information about potential civil or criminal violations from reviewers; it does not handle releases of a beneficiary's information to third parties. Option b is incorrect because the Medicare manual calls for written authorization sent to the MAC, so a spoken statement does not meet the requirement for releasing information. Option c is incorrect because central office direction concerns requests from OIG or DOJ to suspend redeterminations, not a beneficiary's decision to release information to someone else.

Correct Answer: Redetermination decisions and status inquiries, handled as expeditiously as possible without lowering quality

Section 290 states the guidelines apply to appeals correspondence, which includes redeterminations decisions and inquiries about the status of appeals. These are to be handled as expeditiously as possible without lowering the quality of the response. Option a is incorrect because the guidelines call for expeditious handling that keeps response quality intact, and they say nothing about a receipt-order rule or about disregarding quality. Option c is incorrect because redeterminations decisions are also named as appeals correspondence, so this scope omits the main written product the guidelines cover. Option d is incorrect because the guidelines name status inquiries as part of appeals correspondence as well, so limiting the scope to decisions leaves out a covered item.

Correct Answer: Appeal decision placed at the beginning

Medicare guidelines on required elements in appeals correspondence state that the appeal determination or decision is placed in the beginning of the letter. A draft that holds the outcome until the last paragraph does not meet this element. Option b is incorrect because that element governs how a Medicare law citation is written at the end of a sentence, not where the decision sits in the letter. Option c is incorrect because the draft's problem is where the outcome appears; a telephone number is a separate element that concerns contact for further questions, not the order of content. Option d is incorrect because this element applies when the person is to receive another response, such as an MSN, and says nothing about where the decision belongs.