Certified Revenue Cycle Representative (CRCR) Practice Exam

A claim is denied for all of the following reasons, EXCEPT:

1. The health plan cannot identify the subscriber

2. The frequency of service was outside the coverage timeline

3. The submitted claim does not have the physician's signature

4. The subscriber was not enrolled at the time of service

The correct answer is: The submitted claim does not have the physician's signature

The selected answer is appropriate because it identifies a situation that typically does not lead to a claim denial. Claims that lack a physician's signature can often be resolved through additional documentation or follow-up with the provider, allowing for rectification before a final denial occurs. While a signed claim is necessary for processing, it is usually not a definitive reason for outright denial; instead, it often allows for resubmission with the required signature. In contrast, the other reasons represent more concrete issues that directly affect the eligibility and processing of a claim. For instance, if the health plan cannot identify the subscriber, it indicates a fundamental problem with the patient's enrollment or insurance details. Likewise, claims submitted after the coverage timeline is generally considered for denial as they fall outside the authorized service period. Finally, if the subscriber was not enrolled at the time of service, that directly impacts the payer’s responsibility to cover the medical costs, often resulting in a claim denial as the service occurred without valid coverage.