To achieve widespread use of electronic data interchange (EDI) in the healthcare industry, all entities within the industry need to agree on industry standards regarding the information format and software to be used. Several organizations are making cont
Which of the following is CORRECT?
When determining the premium rates it will charge a particular group, the Blue Jay Health Plan used a rating method known as community rating by class (CRC). Under this rating method, Blue Jay
The following statement(s) can correctly be made about the characteristics of reports that should be provided to managers for use in managing a healthcare delivery system:
The process of calculating the appropriate premium to charge purchasers, given the degree of risk represented by the individual or group, the expected costs to deliver medical services, and the expected marketability and competitiveness of the health plan
Which of the following factors have contributed to the limited popularity of FSAs
The following statements are about accreditation in health plans. Select the answer choice that contains the correct statement.
The Titanium Health Plan and a third-party administrator (TPA) have entered into a TPA agreement with regard to the administration of a particular health plan. This agreement complies with all of the provisions of the NAIC TPA Model Law. One of the TPA's
Which out of the three is accomplished through precertification?
IROs stands for
Disease management is typically set up as a voluntary outreach and support program for plan members with certain _________ diseases
Diabetic patients with high glucose levels requiring stabilization following treatment of an acute attack would best be served in an ___________
Select the correct statement regarding TRICARE Extra plan options to military personnel’s.
The following statements apply to flexible spending arrangements. Select the answer choice that contains the correct statement.
Which is an advantage of a for-profit health plan?
The act which requires each group health plan to allow employees and certain dependents to continue their group coverage for a stated period of time following a qualifying event that causes the loss of group health coverage is:
In order to measure the expenses of institutional utilization, Holt Health care group uses standard formula to calculate hospital bed stays per 1000 plan members. On 26 November, Holt uses the following information to:
Calculate the bed days per 1000 members for the MTD
Total gross hospital bed days in MTD = 500
Plan membership = 15000
Calculate Holt's number of bed days per 1000 members for the month to date, rounded to the nearest whole number.
Which of the following people would be considered part of the individual market segment?
The agreement by two or more independent competitors on the prices or fees that they will charge for services is known as:
One feature of the Employee Retirement Income Security Act (ERISA) is that it:
The Ark Health Plan, is currently recruiting providers in preparation for its expansion into a new service area. A recruiter for Ark has been meeting with Dr. Nan Shea, a pediatrician who practices in Ark's new service area, in order to convince her to be
The Azure Group is a for-profit health plan that operates in the United States. The Fordham Group owns all of Azure's stock. The Fordham Group's sole business is the ownership of controlling interests in the shares of other companies. This information ind
The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement. Advances in computer technology have revolutionized the processing of medical and drug claims. Claims processing i
Individuals can use HSAs to pay for the following types of health coverage:.
Managed behavioral health organizations (MBHOs) use several strategies to manage the delivery of behavioral healthcare services. The following statements are about these strategies.
Select the answer choice that contains the correct statement.
The data evaluation stage of utilization review (UR) includes both administrative reviews and medical reviews. One true statement about these types of reviews is that:
Members who qualify to participate in a health plan's case management program are typically assigned a case manager. During the course of the member's treatment, the case manager is responsible for
In the paragraph below, two statements each contain a pair of terms enclosed in parentheses. Determine which term correctly completes each statement. Then select the answer choice containing the two terms that you have chosen. For providers, (operational /
The following paragraph contains an incomplete statement. Select the answer choice containing the term that correctly completes the statement. In early efforts to manage healthcare costs, traditional indemnity health insurers included in their health pla
Paul Gilbert has been covered by a group health plan for two years. He has been undergoing treatment for angina for the past three months. Last week, Mr. Gilbert began a new job and immediately enrolled in his new company's group health plan, which has a
One way in which health plans differ from traditional indemnity plans is that health plans typically
The following sentence contains an incomplete statement with two missing words. Select the answer choice that contains the words that correctly fill the two blanks, respectively. The philosophy of consumer choice involves having consumers play a(n) ______
The contract between the Honolulu MCO and Beverley Hills Hospital contains a 90 day cure provision. The Beverley Hills Hospital breached one of the contract requirements on July 31, 2004. The hospital remedied the problem by October 31, 2004. Which of the
The Advantage Health Plan recently added the following features to its member services program:
1. IVR
2. Active member outreach program
3. Advantage's member services staffing needs are likely to increase as a result of
One distinguishing characteristic of a health maintenance organization (HMO) is that, typically, an HMO
One ethical principle in managed care is the principle of justice/equity, which specifically holds that MCOs and their providers have a duty to
Janet Riva is covered by a traditional indemnity health insurance plan that specifies a $250 deductible and includes a 20% coinsurance provision. When Ms. Riva was hospitalized, she incurred $2,500 in medical expenses that were covered by her health plan.
One ethical principle in health plans is the principle of non-malfeasance, which holds that health plans and their providers:
In order to compensate for lost revenue resulting from services provided free or at a significantly reduced cost to other patients, many healthcare providers spread these unreimbursed costs to paying patients or third-party payors. This practice is known
Health plans can organize under a not-for-profit form or a for-profit form. One true statement regarding not-for-profit health plans is that these organizations typically
In certain situations, a health plan can use the results of utilization review to intervene, if necessary, to alter the course of a plan member's medical care. Such intervention can be based on the results of
Appropriateness of treatment provided is determined by developing criteria that if unmet will prompt further investigation of a claim which are also called:
In 1999, the United States Congress passed the Financial Services Modernization Act, which is referred to as the Gramm-Leach-Bliley (GLB) Act. The following statement(s) can correctly be made about this act:
In assessing the potential degree of risk represented by a proposed insured, a health underwriter considers the factor of anti selection. Anti selection can correctly be defined as the
Brokers are one type of distribution channel that health plans use to market their health plans. One true statement about brokers for health plan products is that, typically, brokers
Ashley Martin is covered by a managed healthcare plan that specifies a $300 deductible and includes a 30% coinsurance provision for all healthcare obtained outside the plan’s network of providers. In 1998, Ms. Martin became ill while she was on vacation,
Immediate evaluation and treatment of illness or injury can be provided in any of the following care settings:
From the following answer choices, choose the description of the ethical principle that best corresponds to the term Autonomy
Health plans sometimes contract with independent organizations to provide specialty services, such as vision care or rehabilitation services, to plan members. Specialty services that have certain characteristics are generally good candidates for health pl
In certain situations, a health plan can use the results of utilization review to intervene, if necessary, to alter the course of a plan member's medical care. Such intervention can be based on the results of
An exclusive provider organization (EPO) operates much like a PPO. However, one difference between an EPO and a PPO is that an EPO
As part of its utilization management (UM) system, the Creole Health Plan uses a process known as case management. The following individuals are members of the Creole Health Plan:
During an open enrollment period in 1997, Amy Hadek enrolled through her employer for group health coverage with the Owl Health Plan, a federally qualified HMO. At the time of her enrollment, Ms. Hadek had three pre-existing medical conditions: angina, fo
During the risk assessment process for a traditional indemnity group insurance health plan, group underwriters consider such characteristics as a group’s geographic location, the size and gender mix of the group, and the level of participation in the grou
In health plan terminology, demand management, as used by health plans, can best be described as