Certified Revenue Cycle Representative (CRCR) Practice Exam

What will lead to a CMS 1500 claim being rejected?

1. The provider is billing with a future date of service

2. Inaccurate patient demographics

3. Insufficient documentation for the service

4. Modification of the billing code

The correct answer is: The provider is billing with a future date of service

Billing with a future date of service will lead to a CMS 1500 claim being rejected because insurance payers typically only process claims for services that have already been rendered. If the date of service is set in the future, the claim does not meet the criteria for processing, as the service has not yet been completed. This fundamentally prevents the payer from validating the provision of care at that time, effectively resulting in an automatic rejection of the claim. Inaccurate patient demographics can hinder the processing of claims but may not necessarily lead to outright rejection. Typically, claims may be denied initially but can sometimes be appealed or corrected if the demographic data is updated. Insufficient documentation can cause issues, as claims may be denied due to lack of supporting evidence for the services billed; however, some payers may allow resubmission if the documentation can later be provided. Modification of the billing code may lead to complications, particularly if the changes are not in line with established coding guidelines, but it does not automatically result in rejection. In many cases, modified codes can be reviewed and accepted if appropriately justified. Thus, billing with a future date of service directly contravenes the operational policies of insurance companies, making it a clear reason for rejection of the claim.