Certified Revenue Cycle Representative (CRCR) Practice Exam

What is a valid reason for a payer to delay processing a claim?

1. Missing social security number

2. Change in coverage type

3. Failure to complete authorization requirements

4. Inadequate billing staff

The correct answer is: Failure to complete authorization requirements

A payer may delay processing a claim if the authorization requirements are not fulfilled. This is because many health plans require pre-authorization for certain procedures or services before they are eligible for reimbursement. Without this authorization, the payer might not proceed with processing the claim, as they need to ensure that the service provided was approved as medically necessary according to their guidelines. This requirement is crucial in controlling costs and preventing unnecessary services, aligning with the payer’s policies and regulations. In contrast, while missing a social security number and changes in coverage type can also lead to delays, they are generally resolvable issues that may not halt the entire claim processing as significantly as unmet authorization requirements would. Inadequate billing staff might cause administrative delays but does not represent a reason established by payer policies that necessitates the processing halt compared to failed authorization.