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NEW QUESTION 1
The Blanchette Health Plan uses a method of claims submission that allows its providers to submit claims directly to Blanchette through a computer application-to-application exchange of claims using a standard data format. This information indicates that Blanchette allows its providers to submit claims using technology known as
- A. Telemedicine
- B. An electronic referral system
- C. Electronic data interchange
- D. Encounter reporting
Answer: C
NEW QUESTION 2
State Medicaid agencies can contract with health plans through open contracting or selective contracting. One advantage of selective contracting is that it
- A. Allows enrollees to choose from among a greater variety of health plans
- B. Reduces the competition among health plans
- C. Increases the ability of new, local plans to participate in Medicaid programs
- D. Encourages the development of products that offer enhanced benefits and more effective approaches to health plans
Answer: D
NEW QUESTION 3
The provider contract that Dr. Bijay Patel has with the Arbor Health Plan includes a no- balance-billing clause. The purpose of this clause is to:
- A. prohibit D
- B. Patel from collecting payments from Arbor plan members for medical services that he provided them, even if the services are explicitly excluded from the benefit plan
- C. allow D
- D. Patel to bill patients for services only if the services are considered to be medically necessary
- E. establish the guidelines used to determine if Arbor is the primary payor of benefits in a situation in which an Arbor plan member is covered by more than one health plan
- F. require D
- G. Patel to accept Arbor's payment as payment in full for medical services that he provides to Arbor plan members
Answer: D
NEW QUESTION 4
Some states have enacted any willing provider laws. From the perspective of the health plan industry, one drawback of any willing provider laws is that they often result in a reduction of a plan’s
- A. Premium rates
- B. Ability to monitor utilization
- C. Number of primary care providers (PCPs)
- D. Number of specialists and ancillary providers
Answer: B
NEW QUESTION 5
As an authorized Medicare+Choice plan, the Brightwell HMO must satisfy CMS requirements regulating access to covered services. In order to ensure that its network provides adequate access, Brightwell must
- A. Allow enrollees to determine whether they will receive primary care from a physician, nurse practitioner, or other qualified network provider
- B. Base a provider’s participation in the network, reimbursement, and indemnification levels on the provider’s license or certification
- C. Define its service area according to community patterns of care
- D. Require enrollees to obtain prior authorization for all emergency or urgently needed services
Answer: C
NEW QUESTION 6
The provider contract that the Canyon health plan has with Dr. Nicole Enberg specifies that she cannot sue or file any claims against a Canyon plan member for covered services, even if Canyon becomes insolvent or fails to meet its financial obligations. The contract also specifies that Canyon will compensate her under a typical discounted fee-for-service (DFFS) payment system.
During its recredentialing of Dr. Enberg, Canyon developed a report that helped the health plan determine how well she met Canyon's standards. The report included cumulative performance data for Dr. Enberg and encompassed all measurable aspects of her performance. This reportincluded such information as the number of hospital admissions Dr. Enberg had and the number of referrals she made outside of Canyon's provider network during a specified period. Canyon also used process measures, structural measures, and outcomes measures to evaluate Dr. Enberg's performance.
The report that helped Canyon determine how well Dr. Enberg met the health plan's standards is known as:
- A. An encounter report
- B. An external standards report
- C. Aprovider profile
- D. An access to care report
Answer: C
NEW QUESTION 7
The following statements are about fee-for-service (FFS) payment systems. Select the answer choice containing the correct statement:
- A. A discounted fee-for-service (DFFS) system is usually easier for a health plan to administer than is a fee schedule system.
- B. A case rate payment system offers providers an incentive to take an active role in managing cost and utilization.
- C. One reason that health plans use a relative value scale (RVS) payment system is that RVS values for cognitive services have traditionally been higher than the values for procedural services.
- D. One reason that health plans use a resource-based relative value scale (RBRVS) is that this system includes weighted unit values for all types of procedures.
Answer: B
NEW QUESTION 8
A health plan that delegates designated credentialing activities to an NCQA-centered or a Commission/URAC-centered credentials verification organization (CVO) is exempt from the due-diligence oversight requirements specified in the NCQA credentialing standards for all
verification services for which the CVO has been certified:
- A. True
- B. False
Answer: A
NEW QUESTION 9
Before incurring the expense of assembling a new PPO network, the Protect Health Plan conducted a cost analysis in order to determine the cost-effectiveness of renting an existing PPO network instead. In calculating the overall cost of renting the network, Protect assumed a premium of $2.52 per member per month (PMPM) and estimated the total number of members to be 9,000. This information indicates that Protect would calculate its annual network rental cost to be
- A. $42,857
- B. $56,700
- C. $272,160
- D. $680,400
Answer: C
NEW QUESTION 10
Jay Mercer is covered under his health plan’s vision care plan, which includes coverage for clinical eye care but not for routine eye care. Recently, Mr. Mercer had a general eye examination and got a prescription for corrective lenses. Mr. Mercer’s vision care plan will cover.
- A. both the general eye examination and the prescription for corrective lenses
- B. the general eye examination only
- C. the prescription for corrective lenses only
- D. neither the general eye examination nor the prescription for corrective lenses
Answer: D
NEW QUESTION 11
From the following answer choices, choose the type of clause or provision described in this situation.
The Idlewilde Health Plan includes in its provider contracts a clause or provision that allows the terms of the contract to renew unchanged each year.
- A. Cure provision
- B. Hold-harmless provision
- C. Evergreen clause
- D. Exculpation clause
Answer: C
NEW QUESTION 12
The provider contracts that the Indigo Health Plan has with its providers include a clause which states that Indigo's denial of payment for a certain medical procedure does not constitute a medical opinion and is not intended to interfere with the provider-patient relationship. This information indicates that Indigo's provider contracts include:
- A. A business confidentiality clause.
- B. A scope of services clause.
- C. An informed refusal clause.
- D. An exculpation clause.
Answer: D
NEW QUESTION 13
The employees of the Trilogy Company are covered by a typical workers' compensation program. Under this coverage, Trilogy employees are bound by the exclusive remedy doctrine, which most likely:
- A. Allows Trilogy to deny benefits for an employee's on-the-job injury or illness, but only if Trilogy is not at fault for the injury or illness.
- B. Allows Trilogy to place limits on the amount of coverage payable for a given claim under the workers' compensation program.
- C. Requires the employees to accept workers' compensation as their only compensation in cases of work-related injury or illness.
- D. Provides the employees with 24-hour coverage.
Answer: C
NEW QUESTION 14
Health plan contract negotiations with an integrated delivery system (IDS) or a hospital are usually lengthier and more complex than negotiations with a single-specialty provider.
- A. True
- B. False
Answer: A
NEW QUESTION 15
A provider group purchased from an insurer individual stop-loss coverage for primary and specialty care services with an $8,000 attachment point and 10% coinsurance. If the group's accrued cost for the primary and specialty care treatment of one patient is $10,000, then the amount that the insurer would be responsible for reimbursing the provider group for these costs is:
- A. $200
- B. $1,000
- C. $1,800
- D. $9,000
Answer: C
NEW QUESTION 16
The Gardenia Health Plan has a national reputation for quality care. When Gardenia entered a new market, it established a preferred provider organization (PPO), a health maintenance organization (HMO), and a point-of-service product (POS) to serve the plan members in this market. All of the providers included in the HMO or the POS are included in the broader provider panel of the PPO. The POS will be a typical two-level POS that offers a cost-based incentive plans for PCPs, and the HMO is a typical staff model HMO.
The following statement(s) can correctly be made about Gardenia’s establishment of the PPO and the staff model HMO in its new market:
* 1. When establishing its PPO network, Gardenia most likely initiated outcomes measurement tools and developed collaborative process improvement relationships with providers.
* 2. To avoid high overhead expenses in the early stages of market evelopment, Gardenia’s HMO most likely contracted with specialists and ancillary providers until the plan’s membership grew to a sufficient level to justify employing these specialists.
- A. Both 1 and 2
- B. Neither 1 nor 2
- C. 1 Only
- D. 2 Only
Answer: D
NEW QUESTION 17
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