Certified Clinical Medical Assistant CCMA Practice Test

An MA receives a denial of payment for a patient's cholecystectomy. The reason stated is "noncovered service." If the procedure was deemed emergent by the provider, which of the following actions should the assistant take?

1. Appeal the insurance denial

2. Instruct the patient to contact the insurer about the denial of payment

3. Write off the balance as charity care

4. Notify the provider to bill the patient directly

The correct answer is: Instruct the patient to contact the insurer about the denial of payment

The correct action in this scenario involves appealing the insurance denial. When a procedure, such as a cholecystectomy, is deemed emergent by a provider, it may fall under exceptions or special coverage rules that the standard policy may not initially recognize. Appealing the denial allows for a formal review of the claim by the insurance company, which can lead to a favorable outcome based on the emergent nature of the procedure. It gives the insurance company an opportunity to reconsider the denial, potentially leading to coverage of the cost. The action of instructing the patient to contact the insurer does not actively engage in resolving the denial and may place the onus on the patient, which could lead to confusion or further complications for them. It is more beneficial for the medical assistant to facilitate the appeal process, as they often have the necessary information and understanding of the situation to represent the case effectively.