Certified Inpatient Coding (CIC) Practice Exam

Which type of medical review involves requesting additional documentation for claims?

1. Non-complex

2. Automated

3. Simple

4. Complex

The correct answer is: Complex

The type of medical review that involves requesting additional documentation for claims is known as a complex review. In this process, healthcare payers or auditors evaluate medical records and may require extra information from providers if initial data submitted is insufficient to support a claim or determine medical necessity. The complex review typically applies to situations where the claim is not straightforward, requiring a deeper analysis of the clinical documentation and potentially additional records from the healthcare provider to substantiate the service rendered. This is in contrast to simpler review types. Non-complex reviews generally handle straightforward claims and do not require further documentation. Automated reviews are performed through a system that assesses claims based on pre-set rules and algorithms, which do not involve direct provider interaction for additional records. Simple reviews may also entail general assessments but lack the depth and detail associated with complex evaluations. Thus, complex reviews are specifically designed to delve into the intricacies of cases that necessitate further evidence and documentation for thorough assessment.