Certified Revenue Cycle Representative (CRCR) Practice Exam

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

1. Insufficient documentation of previous services

2. Failure to complete authorization requirements

3. Missing patient demographics

4. Non-compliance with hospital policies

The correct answer is: Failure to complete authorization requirements

A valid reason for a payer to delay processing a claim is the failure to complete authorization requirements. Authorization is a critical step in the claims process, particularly for certain procedures or treatments that require prior approval from the insurance company. Without this pre-authorization, payers will not process the claim, as they need confirmation that the service is covered under the patient’s insurance plan and that the treatment is medically necessary. When authorization is not obtained, the payer may need to return the claim to the provider for corrections, leading to delays. Completing authorization also ensures that both the provider and the patient are aware of any potential coverage issues before services are rendered, which can help mitigate future conflicts regarding payment for services provided. Insufficient documentation of previous services, missing patient demographics, and non-compliance with hospital policies may also result in claim delays or denials, but the specific focus on authorization requirements directly ties to the payer's responsibility to verify the legitimacy of the claim before processing.