NEW QUESTION 1

One of the most influential pieces of legislation in the advancement of health plans within the United States was the Health Maintenance Organization (HMO) Act of 1973. One of the provisions of the Act was that it

• A. exempted HMOs from all state licensure requirements.
• B. required all employers that offered healthcare coverage to their employees to offer only one type of federally qualified HMO.
• C. eliminated funding that supported the planning and start-up phases of new HMOs.
• D. established a process by which HMOs could obtain federal qualification

Answer: D

NEW QUESTION 2

The existing committees at the Majestic Health Plan, a health plan that is subject to the requirements of HIPAA, include the Executive Committee and the Corporate Compliance Committee. The Executive Committee serves as a long-term advisory body on issues

• A. Both 1 and 2
• B. 1 only
• C. 2 only
• D. Neither 1 nor 2

Answer: B

NEW QUESTION 3

The existing committees at the Majestic Health Plan, a health plan that is subject to the requirements of HIPAA, include the Executive Committee and the Corporate Compliance Committee. The Executive Committee serves as a long-term advisory body on issues related to overall organizational policy. The Corporate Compliance Committee are convened to address specific management concerns. The following statement(s) can correctly be made about these committees:

• A. Majestic's Executive Committee is an example of a Specific committee.
• B. The Corporate Compliance Committee is an Example of an Adhoc company.
• C. A & B

Answer: B

NEW QUESTION 4

The following organizations are the primary sources of accreditation of healthcare organizations:

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

Answer: A

NEW QUESTION 5

Which of the following statements about EPO & HMO models is FALSE?

• A. In-network visit is allowed only on PCP's referral in HMO model.
• B. Out-of-network visit is not allowed in HMO model.
• C. Out-of-network visit is not allowed in EPO model.
• D. In-network visit is allowed only on PCP's referral in EPO model.

Answer: A

NEW QUESTION 6

The following statements are about federal laws that affect healthcare organizations. Select the answer choice containing the correct response.

• A. The Women's Health and Cancer Rights Act (WHCRA) of 1998 requires health plans to offer mastectomy benefits.
• B. The Health Care Quality Improvement Act (HCQIA) requires hospitals, group practices, and HMOs to comply with all standard antitrust legislation, even if these entities adhere to due process standards that are outlined in HCQIA.
• C. The Newborns' and Mothers' Health Protection Act (NMHPA) of 1996 mandates that coverage for hospital stays for childbirth must generally be a minimum of 24 hours for normal deliveries and 48 hours for cesarean births.
• D. Although the Mental Health Parity Act (MHPA) does not require health plans to offer mental health coverage, it imposes requirements on those plans that do offer mental health benefits.

Answer: D

NEW QUESTION 7

FSA is funded by

• A. Employers
• B. Employee
• C. A & B

Answer: AB

NEW QUESTION 8

In claims administration terminology, a claims investigation is correctly defined as the process of

• A. reporting management information about services provided each time a patient visits a provider for purposes of analyzing utilization and provider practice patterns
• B. obtaining all the information necessary to determine the appropriate amount to pay on a given claim
• C. routinely reviewing and processing a claim for either payment or denial
• D. assigning to each diagnosis or treatment reported on a claim special codes that briefly and specifically describe each diagnosis and treatment

Answer: B

NEW QUESTION 9

Col. Martin Avery, on active duty in the U.S. Army, iseligibleto receive healthcare benefits under one of the three TRICARE health plan options. If Col Avery elects to participate in TRICARE Prime, he will be

• A. able to obtain full benefits for services obtained from network and non-network providers
• B. subject to copayment, deductible, and coinsurance requirements for any medical care he receives
• C. required to formally enroll for coverage and pay an enrollment fee
• D. assigned to a primary care manager who is responsible for coordinating all his care

Answer: D

NEW QUESTION 10

The following statements are about preferred provider organizations (PPOs). Select the answer choice that contains the correct statement.

• A. PPOs generally assume full financial risk for arranging medical services for their members.
• B. PPOs generally pay a larger portion of a member's medical expenses when that member uses in-network providers than when the member uses out-of-network providers.
• C. PPO networks may include primary care physicians and hospitals, but generally do not include specialists.
• D. In a PPO, the most common method used to reimburse physicians is capitation.

Answer: B

NEW QUESTION 11

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

• A. prevent D
• B. Ware from requiring a Riverside member to pay any coinsurance, copayment, or deductibles that the member would normally pay under Riverside's plan
• C. require D
• D. Ware to accept the amount that Riverside pays for medical services as payment in full and not to bill plan members for additional amounts
• E. prevent D
• F. Ware from seeking compensation from patients if Riverside fails to compensate him because of the MCO's insolvency
• G. prevent D
• H. Ware from billing a Riverside member for medical services that are not included in Riverside's plan

Answer: B

NEW QUESTION 12

The following sentence contains an incomplete statement with two missing words. Select the answer choice that contains the words that correctly fill in the missing blanks.
At its core, consumer choice involves empowering healthcare consumers to play a

• A. greater/lesser
• B. greater/greater
• C. lesser/greater
• D. lesser/lesser

Answer: B

NEW QUESTION 13

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

• A. Hill had to have an initial net worth of at least $1.5 million in order to obtain a COA.
• B. The COA most likely exempts Hill from any of State X's enabling statutes.
• C. Hill had to be organized as a partnership in order to obtain a COA
• D. The COA in no way indicates that Hill has demonstrated that it is fiscally sound.

Answer: A

NEW QUESTION 14

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

• A. 1
• B. 2
• C. 1 & 2
• D. Neither 1 nor 2

Answer: B

NEW QUESTION 15

Which of the following job descriptions best match the job of a telephone triage staff
member?

• A. Check patient vitals, write prescriptions, administer drugs.
• B. Greet patients at the door, collect insurance information, schedule appointments, collect payments.
• C. Determine urgency of the condition, notify emergency department, schedule appointments, authorize referrals, provide self-care information.
• D. None of the above.

Answer: C

NEW QUESTION 16

One feature of the Employee Retirement Income Security Act (ERISA) is that it:

• A. Requires self-funded employee benefit plans to pay premium taxes at the state level.
• B. Contains a pre-emption provision, which typically makes the terms of ERISA take precedence over any state laws that regulate employee welfare benefit plans.
• C. Contains strict reporting and disclosure requirements for all employee benefit plans except health plans.
• D. Requires that state insurance laws apply to all employee benefit plans except insured plans.

Answer: B

NEW QUESTION 17

System classifies hundreds of hospital services based on a number of criteria, such as primary and secondary diagnosis, surgical procedures, age, gender, and the presence of complications.

• A. Carve-out
• B. DRG
• C. Global capitation
• D. Partial capitation

Answer: B

NEW QUESTION 18

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

• A. M
• B. Van Note, M
• C. Albrecht, and M
• D. Cromartie
• E. M
• F. Van Note and M
• G. Cromartie only
• H. M
• I. Van Note and M
• J. Albrecht only
• K. M
• L. Albrecht and M
• M. Cromartie only

Answer: C

NEW QUESTION 19

Which of the following factors have contributed to the limited popularity of FSAs

• A. "Use it or lose it" provision
• B. Lack of portability
• C. Only self-employed individuals are eligible for establishing FSAs.
• D. Both A &B

Answer: D

NEW QUESTION 20

Graff Scott is a member of the ABC Health Plan. Whenever she needs non-emergency medical care, sees Dr. Michael Chan, an internist. Ms. Scott cannot self-refer to a specialist, so she saw Dr. Michael Chan when she experienced headaches. Dr. Michael Chan referred her to Dr. Bruce Lee, a neurologist, who had hospitalized at the Polo Hospital for tests. ABC has contracts with Dr. Michael Chan, Dr. Lee, and Polo to provide medical services to its members. The following statements are about Polo's organized system of healthcare. Select the answer choice containing the correct statement

• A. Within Polo's system, M
• B. Scott received primary care from both D
• C. Michael Chan and D
• D. Lee
• E. Polo's system allows its members open access to all of Ultra's participating providers
• F. Polo's network of providers includes D
• G. Michael Chan and D
• H. Lee but not Polo Hospital
• I. Within Polo's system, D
• J. Michael Chan serves as a coordinator of care or gatekeeper for the medical services that M
• K. Scott receives

Answer: D

NEW QUESTION 21

Which out of the three is accomplished through precertification?

• A. Concurrent review
• B. Retrospective review
• C. Prospective review

Answer: C

NEW QUESTION 22

Utilization data can be transmitted to the health plan manually, by telephone, or electronically. Compared to other methods of data transmittal, manual transmittal is generally

• A. less cumbersome and labor intensive
• B. faster and more accurate
• C. more acceptable to physicians
• D. subject to greater scrutiny by regulatory bodies

Answer: C

NEW QUESTION 23

The Mabry County Hospital negotiated a contract with Wellfolk HMO. Mabry negotiated the inclusion of a provision in the contract whereby Mabry agreed to capitated compensation from Wellfolk up to a specified total cost of providing medical services for an

• A. quality assurance provision
• B. performance-based financial provision
• C. dual-choice provision
• D. stop-loss provision

Answer: D

NEW QUESTION 24

The administrative simplification standards described under Title II of HIPAA include
privacy standards to control the use and disclosure of health information. In general, these privacy standards prohibit

• A. all health plans, healthcare providers, and healthcare clearinghouses from using any protected health information for purposes of treatment, payment, or healthcare operations without an individual's written consent
• B. patients from requesting that restrictions be placed on the accessibility and use of protected health information
• C. transmission of individually identifiable health information for purposes other than treatment, payment, or healthcare operations without the individual's written authorization
• D. patients from accessing their medical records and requesting the amendment of incorrect or incomplete information

Answer: D

NEW QUESTION 25

Many HMOs are compensated for the delivery of healthcare to members under a prepaid care arrangement. Under a prepaid care arrangement, a plan member typically pays a

• A. fixed amount in advance for each medical service the member receives
• B. a small fee such as $10 or $15 that a member pays at the time of an office visit to a network provider
• C. a fixed, monthly premium paid in advance of the delivery of medical care that covers most healthcare services that a member might need, no matter how often the member uses medical services
• D. specified amount of the member's medical expenses before any benefits are paid by the HMO

Answer: C

NEW QUESTION 26
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