Medical biller screening questions: claims, denials and appeals, timely filing, payment posting and CPB or CRCS credentials

Medical biller screening questions should confirm which part of billing the candidate has really done (charge entry, claim submission, denials and appeals, payment posting or patient balances), on professional or facility claims, with which payers and systems, and whether they know the rules that decide whether money comes in: claim edits, timely filing limits, appeal deadlines, remittance codes and overpayment returns. As of November 2026, Medicare requires claims within one calendar year of the date of service and allows 120 days from receipt of an initial determination to request a redetermination, so a biller who works Medicare should be able to explain both. Credentials such as AAPC's CPB or AAHAM's CRCS help, but many strong billers hold none.

The medical billing and coding screening questions are built around coders: credentials, code sets, specialties and audits, with a short billing section. This page is for the person who gets claims paid. Errors that start at registration end up in the biller's queue, so the patient access representative screening questions are a useful companion, the medical biller and coder job description template covers the posting itself, and the 30-60-90 day plan for medical billers covers the first quarter after the hire.

Which medical billing job is it?

Ask the client whether claims are professional (the CMS-1500 or 837P) or institutional (the UB-04 or 837I), the main payers including Medicare Advantage and Medicaid managed care plans, the practice management system and clearinghouse, the productivity standard and whether the job is remote.

Which credentials and rules apply?

• Billing credentials. AAPC's Certified Professional Biller (CPB) covers claim submission for commercial payers, Medicare and Medicaid, coverage and coordination of benefits, denials, appeals, payment posting and compliance, and is maintained with annual membership and 36 CEUs every two years. AAHAM's certification ladder starts with the Certified Revenue Cycle Specialist (CRCS) and runs to the Certified Revenue Cycle Executive. HFMA offers the Certified Revenue Cycle Representative (CRCR), and NHA's Certified Billing and Coding Specialist (CBCS) is renewed every two years with 10 continuing education credits.
• Coding credentials. If the biller also assigns codes, AHIMA's coding credentials (CCA, CCS and CCS-P) or AAPC's coding credentials apply; use the coder page for those questions.
• Electronic claims. The HIPAA standard at 45 CFR 162.1102 is the ASC X12 837 transaction, version 5010, in professional and institutional forms.
• Remittance codes. X12's claim adjustment reason codes describe why a claim or line was paid differently than billed, and the group codes CO (contractual obligation), PR (patient responsibility), OA (other adjustment) and PI (payer-initiated reduction) assign responsibility for the amount.
• Medicare timely filing. 42 CFR 424.44 requires claims no later than one calendar year after the date of service, with exceptions for contractor error and retroactive entitlement.
• Medicare appeals. CMS's redetermination page gives 120 days from receipt of the initial determination, presumes receipt five calendar days after the notice date, and sets no minimum amount. Later levels follow if the redetermination is unfavorable.
• Overpayments. 42 CFR 401.305 requires Medicare overpayments to be reported and returned within 60 days of identification (or by the cost report due date if later), suspended for up to 180 days during a timely, good-faith investigation.
• Uninsured and self-pay patients. CMS's No Surprises guidance says providers must give these patients a good faith estimate, and a patient billed at least $400 more than the estimate can use the patient-provider dispute resolution process.

Knockout questions

Claims, denials and appeals questions

1. "A claim comes back rejected by the clearinghouse. What do you do, and how is that different from a denial?"
   • Strong answer: a rejection never reached adjudication, so they fix the error (subscriber ID, provider number, missing modifier) and resubmit quickly; a denial was processed, so they read the reason and remark codes and either correct and reprocess it or appeal.
   • Red flags: treats both the same, or resubmits the unchanged claim and creates duplicates.
2. "Walk me through a denial for missing prior authorization."
   • Strong answer: checks whether an authorization existed but was not linked, asks for a retroactive authorization where the payer allows it, appeals with documentation, and tells the front end so it stops recurring.
   • Red flags: writes it off immediately, or bills the patient.
3. "The provider wants to appeal a Medicare denial. What is the deadline and what goes in the request?"
   • Strong answer: 120 days from receipt of the initial determination, a written request to the Medicare Administrative Contractor with the reason and supporting records, tracked to a decision.
   • Red flags: "We just call them," or confuses Medicare Advantage plan appeals with original Medicare.
4. "How did you prioritize your AR work queue?"
   • Strong answer: timely filing and appeal deadlines first, then dollar value and aging, with payer patterns grouped so one call clears several claims.
   • Red flags: oldest first regardless of deadlines, or whatever the system shows.
5. "Tell me about a denial trend you fixed at the source."
   • Strong answer: a pattern (eligibility, authorization, a modifier, a payer policy), the root cause, the change made with registration or coding, and how they checked it worked.
   • Red flags: no example of trend work.
6. "A payer paid the same claim twice. What do you do?"
   • Strong answer: flags the credit balance, follows the refund policy and the payer contract, and knows Medicare overpayments have a 60-day report-and-return rule.
   • Red flags: "Leave it; it's their mistake."

Posting, patient balances and productivity questions

Example of the arithmetic a revenue cycle candidate should follow, with invented numbers: days in accounts receivable is total AR divided by average daily charges. A practice with $450,000 in AR and $1.35 million in charges over the last 90 days has average daily charges of $15,000, so days in AR is 450,000 ÷ 15,000 = 30. A biller who quotes their department's figure should be able to say how it was calculated.

How does medical billing experience get overstated?

• "Billing and coding" that was charge entry from a superbill. Ask whether they chose codes or entered them.
• "AR follow-up" that was status calls from a script, with no appeals. Ask for the last appeal they wrote.
• "Medicare experience" that was Medicare Advantage plans only. Ask which contractor or plan handled the appeals.
• "Denial management" that was posting zero-pay lines. Ask what they did with them next.
• Team volumes quoted as personal. Ask for their own accounts per day.
• A credential in progress listed as held. Verify with the issuing body.

A 15-minute phone-screen flow

1. Minutes 0 to 2: which billing functions, claim type, payers, systems, remote or onsite, productivity standard.
2. Minutes 2 to 5: knockouts 1 to 5; write down credentials to verify after the call.
3. Minutes 5 to 10: the rejection-versus-denial question and the Medicare appeal question.
4. Minutes 10 to 13: one posting question and the duplicate payment question.
5. Minutes 13 to 15: pay expectations (see salary expectation questions) and next steps.

Scoring

What to put in the submittal

Medical biller: [name]
Functions, last 2 years: [charge entry / submission / AR and denials / posting / patient billing], with volumes
Claim type and payers: [professional or facility], [Medicare, Medicaid, plans, commercial]
Systems: [PM system or EHR], [clearinghouse], [payer portals]
Credentials: [CPB / CRCS / CRCR / CBCS / none], verified [date]
Appeals: [last appeal written, outcome], knows Medicare deadline [yes or no]
Denial trend fixed: [one line]
Posting and reconciliation: [summary]
Productivity and quality: [daily volume], [audit or error rate]
Candidate's own gap: [e.g. "no facility claims; Medicare Advantage only"]

Lawful phrasing

Ask candidates to describe their work without naming patients or sharing real records; see does HIPAA apply to job interviews. The HHS Office of Inspector General says anyone who hires a person on its List of Excluded Individuals/Entities may face civil monetary penalties, and that health care entities should routinely check new hires and current employees against it. Background checks run through a consumer reporting agency follow the FCRA steps in the FCRA background check process, plus any state fair-chance rules. Ask about pay expectations rather than pay history, and state the job's physical demands (long periods at a workstation) rather than asking about health. This page is not legal advice.