Question 8

A particular health plan offers a higher level of benefits for services provided innetwork than for out-of-network services. This health plan requires preauthorization
for certain medical services. With regard to the steps that the health plan's claims e
Choice A: should assume that all services requiring preauthorization have been
preauthorized
Choice B: should investigate any conflicts between diagnostic codes and treatment
codes before approving the claim to ensure that the appropriate payment is made
for the claim
Choice C: need not verify that the provider is part of the health plan's network
before approving the claim at the in-network level of benefits
Choice D: need not determine whether the member is covered by another health
plan that allows for coordination of benefits
Answer : B

Question 19
An HMO that combines characteristics of two or more HMO models is sometimes
referred to as a
Choice A: network model HMO
Choice B: group model HMO
Choice C: staff model HMO
Choice D: mixed model HMO
Answer : D

Question 23
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:
Jill Novacek, who has a chronic respiratory condition.
Abraham Rashad,
Choice A: Ms. Novacek, Mr. Rashad, and Mr. Devereaux.
Choice B: Ms. Novacek and Mr. Rashad only.
Choice C: Ms. Novacek and Mr. Devereaux only.
Choice D: None of these members.

Answer : A

Question 25
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,
Choice A: $300
Choice B: $510
Choice C: $600
Choice D: $810
Answer : D

Question 26
Bart Vereen is insured by both a traditional indemnity health insurance plan, which
is his primary plan, and a managed care plan. Both plans have a typical
coordination of benefits (COB) provision, but neither plan has a nonduplication of
benefits provision
Choice A: 380
Choice B: 130
Choice C: 0
Choice D: 550
Answer : A

Question 35
By definition, a health plan's network refers to the
Choice A: organizations and individuals involved in the consumption of healthcare
provided by the plan
Choice B: relative accessibility of the plan's providers to the plan's participants
Choice C: group of physicians, hospitals, and other medical care providers with
whom the plan has contracted to deliver medical services to its members
Choice D: integration of the plan's participants with the plan's providers
Answer : C

Question 67
Health plans often program into their claims processing systems certain criteria
that, if unmet, will prompt further investigation of a claim. In an automated claims
processing system, these criteria may signal the need for further review when, for
exampl
Choice A: Encounter reports
Choice B: Diagnostic codes
Choice C: Durational ratings
Choice D: Edits
Answer : D

Question 68
Health plans require utilization review for all services administered by its
participating physicians.
Choice A: True
Choice B: False
Choice C:
Choice D:
Answer : B

Question 71
Health plans use the following to determine the number of providers to add to a
network:
Choice A: Staffing ratios
Choice B: Drive time
Choice C: Geographic availability
Choice D: All of the above
Answer : D

Question 91

In most cases, medical errors are caused by breakdowns in the healthcare system
rather than by provider mistakes.
Choice A: True
Choice B: False
Choice C:
Choice D:
Answer : A

Question 105
Janet Riva is covered by a 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. She incurre
Choice A: $1,750
Choice B: $1,800
Choice C: $2,000
Choice D: $2,250
Answer : B

Question 116
Medicaid is a jointly funded federal and state program that provides hospital and
medical expense coverage to low-income individuals and certain aged and disabled
individuals. One characteristic of Medicaid is that
Choice A: providers who care for Medicaid recipients must accept Medicaid
payment as payment in full for services rendered
Choice B: Medicaid requires recipients to pay deductibles, copayments, and
coinsurance amounts for all services
Choice C: Medicaid is always the primary payor of benefits
Choice D: benefits offered by Medicaid programs are federally mandated and do
not vary by state
Answer : A

Question 117

Medicare Advantage product options include:

Choice A: Coordinated care plans, medical savings accounts and national PPOs.
Choice B: Private Fee for Service plans, health care prepayment plans and medical
savings accounts
Choice C: Coordinated care plans, regional PPOs and private fee for service plans
Choice D: Cost contracts, coordinated care programs and medical savings
accounts.
Answer : C

Question 118
Medicare is the federal government program established under Title XVIII of the
Social Security Act of 1965 to provide hospital, medical and other covered benefits
to elderly and disabled persons. Medicare is available for:
Choice A: Persons age 63 or older.
Choice B: Persons with qualifying disabilities (over the age of 63)
Choice C: Persons with end-stage renal disease (ESRD)
Choice D: Low income individuals
Answer : C

Question 120
Member satisfaction is a critical element of a health plan's quality management
program. A health plan can obtain information about member satisfaction with
various aspects of the health plan from
Choice A: surveys completed by members following a visit to a provider
Choice B: surveys sent to plan members who have not received healthcare
services during a specified time period
Choice C: periodic reports of complaints received by member services personnel
Choice D: all of the above
Answer : D

Question 128
One characteristic of disease management programs is that they typically

Choice A: focus on individual episodes of medical care rather than on the

comprehensive care of the patient over time
Choice B: are used to coordinate the care of members with any type of disease,
either chronic or nonchronic
Choice C: focus on managing populations of patients who have a specific chronic
illness or medical condition, but do not focus on patient populations who are at risk
of developing such an illness or condition
Choice D: use clinical practice processes to standardize the implementation of best
practices among providers
Answer : D

Question 147
One typical characteristic of an integrated delivery system (IDS) is that an IDS.
Choice A: Is more highly integrated structurally than it is operationally.
Choice B: Provides a full range of healthcare services, including physician services,
hospital services, and ancillary services.
Choice C: Cannot negotiate directly with health plans, plan sponsors, or other
healthcare purchasers.
Choice D: Performs a single business function, such as negotiating with health
plans on behalf of all of the member providers.
Answer : B

Question 161
Phoebe Urich is covered by a traditional indemnity health insurance plan that
specifies a $500 calendar-year deductible and includes a 20% coinsurance
provision. When Ms. Urich was hospitalized, she incurred $3,000 in medical
expenses that were covered by
Choice A: 1900
Choice B: 2000
Choice C: 2400
Choice D: 2500
Answer : B

Question 192

The following organizations are the primary sources of accreditation of healthcare

organizations:
A. National Committee for Qualty Assurance (NCQA)
B. American Accreditation HealthCare Commission/URAC
Of these organizations, performance data is included i
Choice A: A only
Choice B: B only
Choice C: A and B
Choice D: none of the above
Answer : A

Question 200
The following statement can be correctly made about Medicare Advantage
eligibility:
Choice A: Individuals enrolled in a MA plan must enroll in a stand-alone Part D
prescription drug plan.
Choice B: Individuals enrolled in a MA plan do not have to be eligible for Medicare
Part A
Choice C: Individuals enrolled in an MSA plan or a PFFS plan without Medicare drug
coverage can enroll in Medicare Part D.
Choice D: Individuals can enroll in MA plan in multiple regions.
Answer : C