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AHIP AHM-250 Exam - Topic 3 Question 109 Discussion

Health plans often program into their claims processing systems certain criteria that, if unmet, will prompt further investigation of a claim. In an automated claims processing system, these criteria may signal the need for further review when, for example
D) Edits
A) Encounter reports
B) Diagnostic codes
C) Durational ratings

AHIP AHM-250 Exam - Topic 3 Question 109 Discussion

Actual exam question for AHIP's AHM-250 exam
Question #: 109
Topic #: 3
[All AHM-250 Questions]

Health plans often program into their claims processing systems certain criteria that, if unmet, will prompt further investigation of a claim. In an automated claims processing system, these criteria may signal the need for further review when, for example

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Suggested Answer: D

by Verlene at Mar 20, 2025, 11:15 AM

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Laticia
7 months ago
Wait, edits? Really? That seems too vague.
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Gregoria
7 months ago
I think diagnostic codes are more common for that.
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Walker
8 months ago
I feel like durational ratings could be relevant, but they might not be as common as edits or diagnostic codes in claims processing.
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Cordell
8 months ago
Encounter reports can definitely trigger reviews.
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Paris
8 months ago
Totally agree, edits are often overlooked in claims!
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Tamesha
8 months ago
Durational ratings? Never heard of that being a red flag.
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Ivan
8 months ago
Encounter reports sound familiar, but I can't recall if they specifically lead to further investigation. Maybe it's more about the codes?
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Olen
9 months ago
I practiced a similar question where edits were mentioned as criteria for review. That seems like a strong possibility here too.
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Adolph
9 months ago
I think I remember something about diagnostic codes being a key factor in triggering further reviews, but I'm not entirely sure.
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Vince
9 months ago
This seems like a straightforward question about claims processing systems. I think I can handle this one.MikeS: Hmm, I'm not totally sure about the differences between these options. I'll have to think it through carefully.SarahP: Okay, let's see. I know that diagnostic codes and edits are important in claims processing, so I'll focus on those as I consider the answer.TomH: Wait, what's the difference between encounter reports and durational ratings? I'm a little confused by the wording here.LisaM: I've reviewed similar questions before, so I feel pretty confident about this one. I'll eliminate the options that don't seem relevant and go from there.
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Amalia
9 months ago
I've reviewed similar questions before, so I feel pretty confident about this one. I'll eliminate the options that don't seem relevant and go from there.
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Carlee
10 months ago
Wait, what's the difference between encounter reports and durational ratings? I'm a little confused by the wording here.
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Shantay
10 months ago
Okay, let's see. I know that diagnostic codes and edits are important in claims processing, so I'll focus on those as I consider the answer.
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Valda
10 months ago
Hmm, I'm not totally sure about the differences between these options. I'll have to think it through carefully.
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Miss
10 months ago
This seems like a straightforward question about claims processing systems. I think I can handle this one.
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Filiberto
1 year ago
Haha, I bet the exam writers are having a field day tripping us up with these tricky claims processing questions.
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Glory
1 year ago
C) Durational ratings
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Nakisha
1 year ago
B) Diagnostic codes
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Justine
1 year ago
A) Encounter reports
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Carin
1 year ago
I was leaning towards C. Durational ratings, but now I'm second-guessing myself. Decisions, decisions!
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Claribel
1 year ago
C) Durational ratings
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Bea
1 year ago
B) Diagnostic codes
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Serina
1 year ago
A) Encounter reports
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Kiley
1 year ago
B. Diagnostic codes makes the most sense to me. Those are the key factors health plans look at to trigger additional scrutiny.
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Dante
1 year ago
D) Edits
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Della
1 year ago
C) Durational ratings
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Shannon
1 year ago
B) Diagnostic codes
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Bulah
1 year ago
A) Encounter reports
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Dominque
1 year ago
Hmm, I'm pretty sure it's D. Edits. That's the classic way health plans flag claims for further review.
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Merilyn
1 year ago
Yes, edits are commonly used in automated claims processing systems to prompt further investigation.
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Berry
1 year ago
I think you're right, edits are definitely used to flag claims for further review.
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Reed
1 year ago
I believe it could also be D) Edits, as they can trigger a review process.
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Stefanie
1 year ago
I agree with Shay, diagnostic codes are crucial for further investigation.
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Shay
1 year ago
I think the answer is B) Diagnostic codes.
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