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Q: 1
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 example
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Q: 2
To set up and contribute to an HSA, an individual must:
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Q: 3
Merle Spencer has coverage under both Medicare Part A and Medicare Part B. Ms. Spencer recently was hospitalized for chest pains, and she incurred charges for: -The cost of hospitalization for two days -Diagnostic tests performed in the hospital -Trans
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Q: 4
One device that PBM plans use to manage both the cost and use of pharmaceuticals is a formulary. A formulary is defined as
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Q: 5
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
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Q: 6
One type of physician-only integration model is a consolidated medical group. Typical characteristics of a consolidated medical group include
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Q: 7
The Cleopatra Group, a third-party administrator (TPA), has entered into a TPA agreement with the Alexander MCO with regard to the administration of a particular health plan. This agreement complies with all of the provisions of the NAIC TPA Model Law. On
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Q: 8
Traditional Medicare includes two parts: Medicare Part A and Medicare Part B. With regard to the ways these parts differ from each other, it is correct to say that Medicare Part A
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Q: 9
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:
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Q: 10
The National Association of Insurance Commissioners (NAIC) developed the Small Group Model Act to enable small groups to obtain accessible, yet affordable, group health benefits. The model law limits the rate spread, which is the difference between the highest and lowest rates that a health plan charges small groups, to a particular ratio. According to the Model Act, for example, if the lowest rate an HMO charges a small group for a given set of medical benefits is $40, then the maximum rate the HMO can charge for the same set of benefits is
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