Ed Murray is a claims analyst for a managed care plan that provides a higher level of benefits for services received in-network than for services received out-of-network.
Whenever Mr. Murray receives a health claim from a plan member, he reviews the claim
Answer : A
Appropriateness of treatment provided is determined by developing criteria that if unmet will prompt further investigation of a claim which are also called:
Answer : C
In the paragraph below, a sentence contains two pairs of words enclosed in parentheses.
Determine which word in each pair correctly completes the sentence. Then select the answer choice containing the two words that you have chosen. Many pharmacy benefit
Answer : A
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
Answer : C
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
Answer : D
Consumer-directed health plans are not a new concept. They actually got their start in the late 1970s with the advent of:
Answer : D
From the following answer choices, choose the description of the ethical principle that best corresponds to the term Beneficence
Answer : B
Ian Vladmir wants to have a routine physical examination to ascertain that he is in good health. Mr. Vladmir is a member of a health plan that will allow him to select the physician of his choice, either from within his plan's network or from outside of h
Answer : C
All CDHP products provide federal tax advantages while allowing consumers to save money for their healthcare.
Answer : A
The following statements describe two types, or models, of HMOs:
The Quest HMO has contracted with only one multi-specialty group of physicians. These physicians are employees of the group practice, have an equity interest in the practice, and provide
Answer : B
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 plans network of providers. In 1998, Ms. Martin became ill while she was on vacation,
Answer : D
Before the Hill Health Maintenance Organization (HMO) received a certificate of authority
(COA) to operate in State X, it had to meet the state's licensing requirements and financial standards which were established by legislation that is identical to the
Answer : A
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
Answer : B
Because many patients with behavioral health disorders do not require round-the-clock nursing care and supervision, behavioral healthcare services can be delivered effectively in a variety of settings. For example, post-acute care for behavioral health di
Answer : C
By offering a comprehensive set of healthcare benefits to its members, an HMO ensures that its members obtain quality, cost-effective, and appropriate medical care. Ways that an
HMO provides comprehensive care include
Answer : D
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