Question 1

What type of plan is a hybrid of two networks where members may choose from a primary or secondary network?

Accepted Answer

A)   point-of-service (POS)  plans
B)   health maintenance organizations (HMOs) 
C)   preferred provider organizations (PPOs) 
D)   indemnity plans

Question 2

Which section of a managed care participation contract covers referrals and preauthorization rules?

Accepted Answer

A)   compensation and billing guidelines section
B)   physician's responsibilities section
C)   introductory section
D)   managed care plan obligations section

Question 3

A patient's __________ processes the BCBS claim and sends it back to the host plan.

Accepted Answer

A)   heart plan
B)   home plan
C)   hold plan
D)   house plan

Question 4

Self-funded health plans pay premiums to

Accepted Answer

A)   insurance carriers.
B)   no one because they assume the risk.
C)   third-party administrators.
D)   managed care organizations.

Question 5

What is precertification?

Accepted Answer

A)   certification that is awarded pending the successful completion of an exam
B)   requirement for office consultation
C)   preauthorization for hospital admission or outpatient procedures
D)   preauthorization for a practice to join a managed care organization

Question 6

Whether a practice can routinely waiving copayments should be covered in its ______.

Accepted Answer

A)   Office encounter form
B)   Patient information form
C)   Financial policy
D)   Secondary payer agreement

Question 7

What term is used to describe the four types of insurance plans offered by the ACA's public health insurance exchanges?

Accepted Answer

A)   essential health plans
B)   bronze plans
C)   metal plans
D)   individual health plans

Question 8

What is the electronic format used to verify benefits?

Accepted Answer

A)   HIPAA 278
B)   HIPAA 270/271
C)   HIPAA 837
D)   HIPAA 276/277

Question 9

Which of the following is one of the nation's largest health insurers?

Accepted Answer

A)   Anthem
B)   Kaiser Permanente
C)   UnitedHealth Group
D)   Aetna

Question 10

What information is included in a formulary?

Accepted Answer

A)   how drug dosages are calculated and pricing
B)   the improper dosages for the plan's drugs
C)   the list of a plan's selected drugs and proper dosages
D)   pricing on drugs

Question 11

Explain the benefit that COBRA offers to employees who are leaving a job.

Accepted Answer

A)   the right to skip the waiting period
B)   the right to freedom from a maximum benefit limit
C)   the right to parity in selecting their next health plan
D)   the right to continue health coverage under the employer's plan for a limited time at their own expense

Question 12

Which term describes the periodic verification that a provider or facility meets professional standards?

Accepted Answer

A)   credentialing
B)   P4P
C)   regulating
D)   certifying

Question 13

The amount of time that must pass before an employee can enroll in a health plan is called a(n)

Accepted Answer

A)   waiting period.
B)   episode of care.
C)   late period.
D)   host plan.

Question 14

Providers bill patients for services not covered by the cap rate under a(n)

Accepted Answer

A)   encounter report.
B)   capitated contract.
C)   referral.
D)   plan summary grid.

Question 15

Describe the features of managed care organizations that practices review when deciding about entering a participation contract.

Accepted Answer

A)   its business history and licensure status
B)   its licensure status, accreditation standing, and business history
C)   none of these are required when deciding on participation
D)   its accreditation standing only

Question 16

Which type of consumer-driven health plan funding option can be funded by both employers and employees?

Accepted Answer

A)   a flexible savings account (FS
A)  
B)   a health reimbursement account (HR
A)  
C)   a health savings account (HS
A)  
D)   a medical home model

Question 17

What type of surgery is a procedure that can be scheduled ahead of time, but which may or may not be medically necessary?

Accepted Answer

A)   elective surgery
B)   experimental surgery
C)   voluntary surgery
D)   emergency surgery

Question 18

The federal law that regulates companies that set up employee health and pension plans is known as

Accepted Answer

A)   CMS.
B)   FEHBP.
C)   MCO.
D)   ERISA.

Question 19

Name the structure that emphasizes communication among the patient's physicians.

Accepted Answer

A)   episode-of-care option
B)   medical home model
C)   open-panel HMO
D)   independent practice association

Question 20

How can TPAs help self-funded health plans?

Accepted Answer

A)   by handling the process and paying of claims and keeping list of members only
B)   by keeping lists of members up-to-date only
C)   by handling collection of premiums, processing claims, and keeping list of members
D)   by handling the collection of premiums and paying claims only

Exam 8: Private Payers/BlueCross BlueShield

How can TPAs help self-funded health plans?

Correct AnswerverifiedShow Answer

What type of surgery is a procedure that can be scheduled ahead of time, but which may or may not be medically necessary?

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What type of plan is a hybrid of two networks where members may choose from a primary or secondary network?

Correct AnswerverifiedShow Answer

What is precertification?

Correct AnswerverifiedShow Answer

Describe the features of managed care organizations that practices review when deciding about entering a participation contract.

Correct AnswerverifiedShow Answer

Name the structure that emphasizes communication among the patient's physicians.

Correct AnswerverifiedShow Answer

The federal law that regulates companies that set up employee health and pension plans is known as

Correct AnswerverifiedShow Answer

Explain the benefit that COBRA offers to employees who are leaving a job.

Correct AnswerverifiedShow Answer

Which term describes the periodic verification that a provider or facility meets professional standards?

Correct AnswerverifiedShow Answer

What term is used to describe the four types of insurance plans offered by the ACA's public health insurance exchanges?

Correct AnswerverifiedShow Answer

The amount of time that must pass before an employee can enroll in a health plan is called a(n)

Correct AnswerverifiedShow Answer

Whether a practice can routinely waiving copayments should be covered in its ______.

Correct AnswerverifiedShow Answer

Which of the following is one of the nation's largest health insurers?

Correct AnswerverifiedShow Answer

What is the electronic format used to verify benefits?

Correct AnswerverifiedShow Answer

A patient's __________ processes the BCBS claim and sends it back to the host plan.

Correct AnswerverifiedShow Answer

What information is included in a formulary?

Correct AnswerverifiedShow Answer

Which type of consumer-driven health plan funding option can be funded by both employers and employees?

Correct AnswerverifiedShow Answer

Self-funded health plans pay premiums to

Correct AnswerverifiedShow Answer

Providers bill patients for services not covered by the cap rate under a(n)

Correct AnswerverifiedShow Answer

Which section of a managed care participation contract covers referrals and preauthorization rules?

Correct AnswerverifiedShow Answer

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