If left unresolved, member complaints about the actions or decisions made by a health plan or its providers can lead to formal appeals. One procedure health plans can use to address formal appeals is to submit the original decision and any supporting info
Answer : A
Historically most HMOs have been
Answer : B
Eleanor Giambi is covered by a typical 24-hour managed care program. One characteristic of this program is that it:
Answer : B
In order to measure the expenses of institutional utilization, Holt Healthcare Group uses the standard formula to calculate hospital bed days per 1,000 plan members per year. On
October 23, Holt used the following information to calculate the bed days per
Answer : B
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
Answer : D
As part of its utilization management (UM) system, the Poplar MCO uses a process known as case management. The following statements describe individuals who are Poplar plan members:
-> Brad Van Note, age 28, is taking many different, costly medications for
Answer : C
An exclusive provider organization (EPO) operates much like a PPO. However, one difference between an EPO and a PPO is that an EPO
Answer : B
Dr. Milton Ware, a physician in the Riverside MCO's network of providers, is reimbursed under a fee schedule arrangement for medical services he provides to Riverside members.
Dr. Ware's provider contract with Riverside contains a typical no-balance billi
Answer : B
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
Answer : A
A medical foundation is a not-for-profit entity that purchases and manages physician practices. In order to retain its not-for-profit status, a medical foundation must
Answer : A
Amendments to the HMO act 1973 do not permit federally qualified HMO’s to use
Answer : A
Dr. Samuel Aldridge's provider contract with the Badger Health Plan includes a typical due process clause. The primary purpose of this clause is to:
Answer : C
Emily Brown works for Integral Health Plan and represents the company as a board member for the board of directors. Which best describes Emily's position?
Answer : B
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
Answer : D
A particular health plan offers a higher level of benefits for services provided in-network 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
Answer : B