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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
Suggested Answer: D
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34 comments · newest first
LA
Laticia
10 months ago
Wait, edits? Really? That seems too vague.
GR
Gregoria
10 months ago
I think diagnostic codes are more common for that.
WA
Walker
11 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.
CO
Cordell
11 months ago
Encounter reports can definitely trigger reviews.
PA
Paris
11 months ago
Totally agree, edits are often overlooked in claims!
TA
Tamesha
11 months ago
Durational ratings? Never heard of that being a red flag.
IV
Ivan
11 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?
OL
Olen
12 months ago
I practiced a similar question where edits were mentioned as criteria for review. That seems like a strong possibility here too.
AD
Adolph
12 months ago
I think I remember something about diagnostic codes being a key factor in triggering further reviews, but I'm not entirely sure.
VI
Vince
1 year 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.
AM
Amalia
1 year 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.
CA
Carlee
1 year ago
Wait, what's the difference between encounter reports and durational ratings? I'm a little confused by the wording here.
SH
Shantay
1 year 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.
VA
Valda
1 year ago
Hmm, I'm not totally sure about the differences between these options. I'll have to think it through carefully.
MI
Miss
1 year ago
This seems like a straightforward question about claims processing systems. I think I can handle this one.
FI
Filiberto
1 year ago
Haha, I bet the exam writers are having a field day tripping us up with these tricky claims processing questions.
GL
Glory
1 year ago
C) Durational ratings
NA
Nakisha
1 year ago
B) Diagnostic codes
JU
Justine
1 year ago
A) Encounter reports
CA
Carin
2 years ago
I was leaning towards C. Durational ratings, but now I'm second-guessing myself. Decisions, decisions!
CL
Claribel
1 year ago
C) Durational ratings
BE
Bea
1 year ago
B) Diagnostic codes
SE
Serina
1 year ago
A) Encounter reports
KI
Kiley
2 years ago
B. Diagnostic codes makes the most sense to me. Those are the key factors health plans look at to trigger additional scrutiny.
DA
Dante
1 year ago
D) Edits
DE
Della
1 year ago
C) Durational ratings
SH
Shannon
1 year ago
B) Diagnostic codes
BU
Bulah
1 year ago
A) Encounter reports
DO
Dominque
2 years ago
Hmm, I'm pretty sure it's D. Edits. That's the classic way health plans flag claims for further review.
ME
Merilyn
1 year ago
Yes, edits are commonly used in automated claims processing systems to prompt further investigation.
BE
Berry
2 years ago
I think you're right, edits are definitely used to flag claims for further review.
RE
Reed
2 years ago
I believe it could also be D) Edits, as they can trigger a review process.
ST
Stefanie
2 years ago
I agree with Shay, diagnostic codes are crucial for further investigation.
SH
Shay
2 years ago
I think the answer is B) Diagnostic codes.