What are Medical services that are not covered by an individual's B.

Disease Management Correct

insurance policy known as? C. Risk Management Incorrect
Choose one answer. D. Issue Management Incorrect
A. Excursions Incorrect The process in which a plan member may go to a specialist, either
B. Exclusions Correct in-network or out-of-network, at full benefit or at a reduced benefit,
C. Explosions Incorrect without first obtaining a referral from his or her PCP, is called
D. Inclusions Incorrect Choose one answer.
Under a group plan, an HMO member has no contractual A. Self referral Correct
relationship with the MCO B. No referral Incorrect
Choose one answer. C. Special referral Incorrect
A. TRUE Correct D. No referral Incorrect
B. FALSE Incorrect One way in which a managed care plan typically enhances the
Expand JCAHO accessibility of health care is by
Choose one answer. Choose one answer.
A. Judiciary Commission on Accreditation of Healthcare A. requiring plan members to pay a coinsurance amount
Organizations Incorrect for each medical service received Incorrect
B. Joint Commission on Accreditation of Healthcare B. requiring plan members to obtain all healthcare from
Organizations Correct the plans network of providers Incorrect
C. Judiciary Commission on Authorizing of Healthcare C. providing a network wherein members have low cost
Organizations Incorrect access to primary care Correct
D. Joint Commission on Authorizing Healthcare D. discouraging plan members from seeking preventive
Organizations Incorrect healthcare Incorrect
An external organization that conducts reviews to assess the The process of deciding the premium to charge for a health plan or
medical appropriateness of suggested courses of treatment for a given set of benefits, is called
patients, thereby providing the patient and the purchaser increased Choose one answer.
assurance of the value and quality of healthcare services, is called A. Costing Incorrect
Choose one answer. B. Scheduling Incorrect
A. Utilization review Organization Correct C. Charging Incorrect
B. Administrative services organization Incorrect D. Pricing Correct
C. Government Organization Incorrect The committee that oversees the Managed Care organization's
D. School of Medicine Incorrect quality assessment and improvement activities in both clinical and
Health insurance that covers only major hospital and emergency non-clinical areas
costs, is called Choose one answer.
Choose one answer. A. Utilization management committee Incorrect
A. Catastrophic health insurance Correct B. Review committee Incorrect
B. Disaster health insurance Incorrect C. SQA commitee Incorrect
C. Backup health insurance Incorrect D. Quality Management commitee Correct
D. Gap health insurance Incorrect The health plan committee that reviews and updates the health
Insurance Coverage for medical professionals, like doctors that plan's utilization management program is called
protects them if they are accused of providing poor quality care Choose one answer.
Choose one answer. A. Quality Management Committee Incorrect
A. Quality Insurance Incorrect B. Plan Committee Incorrect
B. self insurance Incorrect C. Utilization Management Committee Correct
C. Practice insurance Incorrect D. Accreditation Committee Incorrect
D. Malpractice insurance Correct A fee you pay each time you see a doctor or fill a prescription.
Which is WellPoint’s full-service health plan offered in several Choose one answer.
different regions throughout the country, including those areas A. Co-pay Correct
where the company does not have a licensed Blue plan? B. Co-insurance Incorrect
Choose one answer. C. Deductible Incorrect
A. BCC Incorrect D. premium Incorrect
B. Unicorn Incorrect In the context of health care, what does CDC stand for
C. Unicore Incorrect Choose one answer.
D. Unicare Correct A. Clincal Diagnostic centre Incorrect
___, sometimes known as a medical-necessity review, is a B. Complete disease care Incorrect
program that requires physicians to obtain certification of medical C. Complete deduction count Incorrect
necessity prior to drug dispensing or treatment D. Centre for Disease Control and prevention Correct
Choose one answer. What Does CDHP stand for
A. Approval Incorrect Choose one answer.
B. Review Incorrect A. Customer Driven Health Product Incorrect
C. Prior Authorization Correct B. Consumer Directed Health Plan Correct
D. Pre-certification Incorrect C. Customer Dependant Halth Plan Incorrect
Which part of Medicare covers the costs of physicians D. Consumer Driven Health product Incorrect
Choose one answer. In the context of provider relationships and compensation
A. Part-A Incorrect arrangements, which one is not a model or type of HMO
B. Part-B Correct Choose one answer.
C. Part-C Incorrect A. Network model Incorrect
D. Part-D Incorrect B. IPA model Incorrect
A coordinated system of preventive, diagnostic, and therapeutic C. Staff model Incorrect
measures intended to provide cost-effective, quality healthcare for D. Administration model Correct
a patient population who have or are at risk for a specific CHRONIC A type of managed care system where the health plan employs its
illness or medical condition, is called own doctors. These doctors often work in the health plan's own
Choose one answer. health facility
A. People Management Incorrect Choose one answer.
 A. IPA Incorrect Choose one answer.
B. PPO Incorrect A. Preventive care Correct
C. Staff Model HMO Correct B. In-patient care Incorrect
D. CDHP Incorrect C. Hospice care Incorrect
An organization that administers group benefit plans for self- D. pre-natal care Incorrect
funded groups, is called What is the primary source of revenue for Wellpoint Inc
Choose one answer. Choose one answer.
A. Third Party Administrator Correct A. Premiums for Insurance plans sold Correct
B. Neutral Adminstrator Incorrect B. Claim payments for Insurance plans sold Incorrect
C. Outsourced Administrator Incorrect C. Income from IT business Incorrect
D. In-house Administrator Incorrect D. Income from Investment in shares Incorrect
Which program evaluates whether drugs are being used safely, The type of plan in which an insurer or health plan bears the
effectively, and appropriately responsibility of guaranteeing claim payments, paying for all
Choose one answer. incurred covered benefits, and administering the health plan
A. Drug Safety Review Incorrect Choose one answer.
B. Drug Screening Review Incorrect A. Self funded Incorrect
C. Drug Utilization Review Correct B. Fully funded Correct
D. Physician profiling Incorrect C. Self insured Incorrect
After the group member has paid the deductible amount, most D. None of the above Incorrect
policies also require the group member to pay a stated percentage URAC accreditation is valid for how many years?
of all the remaining eligible medical expenses. This method of cost Choose one answer.
sharing is known as: A. One Incorrect
Choose one answer. B. Two Incorrect
A. Limitation Incorrect C. Three Correct
B. Co-insurance Correct D. Four Incorrect
C. Copay Incorrect The process through which an organization validates credentialing
D. Out of Pocket Incorrect information from the organization that originally conferred the
What is the term used for the listing of drugs, classified by credentialing element to a practitioner is called
therapeutic category or disease class, that are considered preferred Choose one answer.
therapy for a given managed population and that are to be used by A. Validation Incorrect
a health plan's providers in prescribing medications. B. Background check Incorrect
Choose one answer. C. Primary source verification Correct
A. Drug list Incorrect D. Data source verification Incorrect
B. Medicine list Incorrect A form of medical cost sharing in a health insurance plan that
C. Formulary Correct requires an insured person to pay a stated percentage of medical
D. Itemlist Incorrect expenses after the deductible amount, if any, was paid.
An external organization that conducts reviews to assess the Choose one answer.
medical appropriateness of suggested courses of treatment for A. Co-pay Incorrect
patients B. Deductible Incorrect
Choose one answer. C. Co-Insurance Correct
A. Managed Care Corporation Incorrect D. Premium Incorrect
B. Vertical Organization Incorrect To offset "gaps" in coverage under Medicare Part A and Medicare
C. Utilization review Organization Correct Part B, beneficiaries often elect to purchase Medicare supplement
D. Preferred provider Organization Incorrect policies. These policies are called
The separation of a medical service (or a group of services) from Choose one answer.
the basic set of benefits either through a different compensation A. Medifill Incorrect
method for providers or through the use of a separate network or B. Medigap Correct
delivery system is called C. Medi Supplement Incorrect
Choose one answer. D. None of the above Incorrect
A. Split Incorrect Which part of Medicare provides benefits to cover the costs of
B. Carve-out Correct physicians
C. Outsource Incorrect Choose one answer.
D. Separate Incorrect A. Part A Incorrect
The process a health plan uses to determine which benefits or B. Part B Correct
which level of benefits will be offered to its members, the degree to C. Part Z Incorrect
which members will be expected to share the costs of such D. Part D Incorrect
benefits, and how a member can access medical care through the Which of these cost saving techniques is NOT used by indemnity
health plan, is called plans?
Choose one answer. Choose one answer.
A. Code design Incorrect A. Use of Deductibles & co-insurance Incorrect
B. Marketing design Incorrect B. Employee wellness & disease prevention programs
C. Benefit Design Correct Incorrect
D. None of the above Incorrect C. Promoting outpatient alternatives Incorrect
A benefit plan that gives workers a set amount of dollars and lets D. Underwriting Correct
them choose which health care and other benefits they want, is The process that involves compiling data on physician prescribing
called patterns and comparing physicians
Choose one answer. Choose one answer.
A. Cafe Plan Incorrect A. Physician profiling Correct
B. Cafeteria Plan Correct B. Physical profiling Incorrect
C. Restaurant plan Incorrect C. Drug profiling Incorrect
D. Bouquet plan Incorrect D. None of the above Incorrect
Health care services that help prevent disease. Flu shots and Pap Give the full form of NCPDP?
smears are examples Choose one answer.
 A. Neutral Council for Prescription Drug Programs Choose one answer.
Incorrect A. HMO Incorrect
B. Natural customer for Prescription Drug Programs B. PPO Incorrect
Incorrect C. POS Incorrect
C. National Council for Prescription Drug Programs D. HDHP Correct
Correct Although the United States does not have a national health care
D. New Council for Prescription Drug Programs Incorrect program for all of its residents, there are several government-
A health problem that you had before you became a member of a sponsored health insurance programs.Name the health care
health plan. Health plans do not always cover services to treat insurance for U.S. citizens who are of age 65 or older
these conditions Choose one answer.
Choose one answer. A. Mediclaim Incorrect
A. Terminal condition Incorrect B. Mediassist Incorrect
B. Pre existing condition Correct C. Medicare Correct
C. Prior condition Incorrect D. Medicure Incorrect
D. Fever Incorrect What information does a 'Provider Manual' contain
An evaluative process in which a healthcare organization Choose one answer.
undergoes an examination of its operations'processes to determine A. provider's rights and responsibilities Correct
if they meet designated criteria as defined by the accreditation B. provider's hobbies Incorrect
organization is called C. provider's family details Incorrect
Choose one answer. D. none of the above Incorrect
A. Enrolment Incorrect One of the clinical services provided by a Pharmacy Benefits
B. Examination Incorrect Management company (PBM) focuses on compiling data on
C. Accreditation Correct physicians prescribing patterns and then comparing physicians
D. Profiling Incorrect actual patterns to expected patterns within selected drug
The process of identifying and classifying the potential degree of categories. The PMB then targets abberant prescribers for
risk represented by an insurance applicant, also called selection of educational intervention. This service provided by a PBM is known
risks, is called as
Choose one answer. Choose one answer.
A. Risk Monitoring Incorrect A. formulatory management Incorrect
B. Underwriting Correct B. physician profiling Correct
C. Coverage Incorrect C. risk adjustment Incorrect
D. Rationalization Incorrect D. Drug Utilization Review (DUR) Incorrect
Which type of health insurance offers the most choice in terms of The time when you can re-enroll in the health plan you are already
health care professionals you can see and get reimbursed for? in or choose to enroll in another health plan.
Choose one answer. Choose one answer.
A. HMO Incorrect A. Time slot Incorrect
B. PPO Incorrect B. Open slot Incorrect
C. POS Incorrect C. Open period Incorrect
D. FFS Correct D. Open enrollment period Correct
The agreed upon fees paid by a subscriber to the Payer, for A system in which the appropriateness of healthcare services
coverage of medical benefits for a defined benefit period. delivered by a provider to health plan members is evaluated by a
Choose one answer. panel of medical professionals
A. Co-pay Incorrect Choose one answer.
B. Deductible Incorrect A. Peer review Correct
C. Co-Insurance Incorrect B. Walkthrough Incorrect
D. Premium Correct C. Concurrent review Incorrect
A database maintained by the federal government that contains D. Code review Incorrect
information on physicians and other medical practitioners against A flat amount that a group member must pay before the insurer will
whom medical malpractice claims have been settled or other make any benefit payments:
disciplinary actions have been taken. Choose one answer.
Choose one answer. A. Co-insurance Incorrect
A. Natural Provider database Incorrect B. Copay Incorrect
B. National Provider database Incorrect C. Deductible Correct
C. National Practitioner database Correct D. Out of Pocket Incorrect
D. None of the above Incorrect In the context of health care insurance, Re-credentianlling comes
Expand: HIPAA under which process below
Choose one answer. Choose one answer.
A. Health Insurance Payable Act of Accountability A. Utilization management Incorrect
Incorrect B. Quality management Correct
B. Health insurance Privacy and Accountability Act. C. Financial management Incorrect
Incorrect D. Patient management Incorrect
C. Health Insurance Policy of Accountability Act Incorrect Which is a mechanism designed to aid providers in making
D. Health insurance Portability and Accountability Act. decisions about the most appropriate course of treatment for a
Correct specific clinical case.
The set of benefits the health plan designs and packages for sale Choose one answer.
to the employer is called A. Drug practice guidelines Incorrect
Choose one answer. B. Pharmacy practice guidelines Incorrect
A. Market Incorrect C. Clinical practice guidelines Correct
B. Product Correct D. Diagnosis practice guidelines Incorrect
C. Sale Incorrect A person named John is covered by health insurance plan that
D. Goods Incorrect specifies a $500 calendar-year deductible and includes a 20%
Which health insurance plan typically has a higher deductible than coinsurance provision. When John was hospitalized, he incurred
other insurance products $3,000 in medical expenses that were covered by his health plan.
He incurred no other medical expenses during the calendar year. D. Non-Participating Provider Incorrect
With regard to the $3,000 of medical expenses, the amount that the In the context of Health care Insurance, the computer-to-computer
insurer was obligated to pay was exchange of information between companies, using a common
Choose one answer. standard format is called
A. $1900 Incorrect Choose one answer.
B. $2000 Correct A. Electronic data Interaction Incorrect
C. $2400 Incorrect B. Electrical data Interchange Incorrect
D. $2500 Incorrect C. Electronic data Interchange Correct
Care given to terminally ill patients, is called D. Electronic data exchange Incorrect
Choose one answer. What is the approximate Number of members for WellPoint
A. Term care Incorrect currently has?
B. Hospice care Correct Choose one answer.
C. out-patient care Incorrect A. 25 Million Incorrect
D. Home health care Incorrect B. 35 Million Correct
Libra MCO wants to imprive its service quality. Libras managers C. 45 Million Incorrect
first identify a competitor with extremely high service quality. Libras D. 55 Million Incorrect
managers then analyze the competitors practices and implemented Which option below is NOT a typical rating methods used by health
them in Libras organization. This information indicates that Libra plans in setting premiums?
has attempted in improving its service quality by using a practice Choose one answer.
known as A. Automatic Correct
Choose one answer. B. Manual Incorrect
A. case-mix adjustment Incorrect C. Experience Incorrect
B. a standard of care Incorrect D. Community Incorrect
C. a functional status review Incorrect The money you have to pay for health services after you have paid
D. benchmarking Correct the deductible
Medical services that a health plan will not cover Choose one answer.
Choose one answer. A. Co-pay Incorrect
A. Inclusions Incorrect B. Co-insurance Correct
B. Excursions Incorrect C. Deductible Incorrect
C. Exclusions Correct D. premium Incorrect
D. Excuses Incorrect Which plan does not permit the insured to choose their own
The process followed to settle health insurance claims is called doctors?
Choose one answer. Choose one answer.
A. Claims processing Incorrect A. HMO Correct
B. Adjudication Correct B. PPO Incorrect
C. Auto-processing Incorrect C. CDHP Incorrect
D. Advertisement Incorrect D. FFS Incorrect
A monthly fee you pay for health care coverage. A health plan's periodic review of the qualifications of a current
Choose one answer. network provider to verify that the provider still meets the standards
A. Co-pay Incorrect for participation in the network
B. Co-insurance Incorrect Choose one answer.
C. Deductible Incorrect A. Recredentialling Correct
D. premium Correct B. Re-verification Incorrect
What is the term used when a member pay one copayment C. Interim review Incorrect
amount for a generic drug and a higher copayment amount for a D. Periodic review Incorrect
brand-name drug Under COBRA, how long can you keep your employer-offered
Choose one answer. health insurance in the case of life changing events such as job
A. dual copayment strucuture Incorrect loss, death, divorce etc (assuming your employer has at least 20
B. multi copayment structure Incorrect employees)?
C. two-tier copayment structure Correct Choose one answer.
D. Cascade copayment structure Incorrect A. 12 Months Incorrect
The dispensing of a drug that is the generic equivalent of a drug B. 18 Months Correct
listed on a pharmacy benefit management plan's formulary, is C. 24 Months Incorrect
called D. 48 Months Incorrect
Choose one answer. Which of the below is a performance-measurement tool,
A. Generic substitution Correct administered by NCQA, designed to help healthcare purchasers
B. Specific substitution Incorrect and consumers compare the quality offered by different health
C. Direct substitution Incorrect plans.
D. Direct replacement Incorrect Choose one answer.
Which Act accelerated the consumer-directed healthcare A. Orion Incorrect
movement by implementing the most recent CDHP option - the B. HEDIS Correct
health savings account C. HIPAA Incorrect
Choose one answer. D. None of the Above Incorrect
A. Any Willing Provider Act Incorrect Which ACT facilitated the creation of the National Practitioner Data
B. Medicare Modernization Act of 2003 Correct Bank
C. HMO Act Incorrect Choose one answer.
D. Ethics in Patient referrals Act Incorrect A. Health care financial improvement Act Incorrect
A health professional who contracts with a health plan. This health B. HMO Act Incorrect
professional delivers medical services to covered members. C. Health care quality improvement Act Correct
Choose one answer. D. HIPAA Incorrect
A. Contractor Incorrect Which plan is hybrid of HMO & PPO?
B. Consultant Incorrect Choose one answer.
C. Participating Provider Correct A. CDHP Incorrect
 B. HRA Incorrect D. MSA Incorrect
C. POS Correct A pharmacy benefit copayment system under which a member is
D. FSA Incorrect required to pay one copayment amount for a generic drug, a higher
Documentation errors in which a treatment is miscoded or the copayment amount for a brand-name drug included on the health
codes used to describe procedures do not match those used to plan's formulary, and an even higher copayment amount for a non-
identify the diagnosis. formulary drug.
Choose one answer. Choose one answer.
A. Coding errors Correct A. Three-tier copay Correct
B. Development errors Incorrect B. Differential copay Incorrect
C. Build errors Incorrect C. Multi copay Incorrect
D. None of the above Incorrect D. None of the above Incorrect
Expand EDI Benchmarking, Clinical practice guidelines, Provder profiling, peer
Choose one answer. review are tools used for
A. Electronic Data Interchange Correct Choose one answer.
B. Electric DAta Information Incorrect A. Demand management Incorrect
C. Electric Data Interchange Incorrect B. Case management Incorrect
D. Elect Data Infomation Incorrect C. Disease management Incorrect
Which ACT requires employers with 20 or more employees to let D. Quality Management Correct
employees and their dependents keep their health coverage for a Which Law restricts restrict a managed care organization's ability
time after they leave their employment, under certain conditions. to terminate physicians without cause from participation in a
Choose one answer. particular insurance plan.
A. HMO Act Incorrect Choose one answer.
B. PPO Act Incorrect A. HIPAA Incorrect
C. CDHP Act Incorrect B. Any willing Provider Law Correct
D. COBRA Correct C. COBRA Incorrect
Which of the following is not a preventive care program D. CDHP Incorrect
Choose one answer. A form of medical cost sharing in a health insurance plan that
A. Immunization Incorrect requires an insured person to pay a fixed dollar amount when a
B. Health promotion programs Incorrect medical service is received. The insurer is responsible for the rest
C. Surgery Correct of the reimbursement.
D. Screening programs Incorrect Choose one answer.
Insurance plan is offered by private insurance companies to give A. Co-pay Correct
coverage for something which is not covered under B. Deductible Incorrect
Medicare/Medicaid C. Co-Insurance Incorrect
Choose one answer. D. Premium Incorrect
A. Medigap Correct The process by which a health plan uses information about a plan
B. Medifill Incorrect member
C. Mediclaim Incorrect Choose one answer.
D. Mediassist Incorrect A. Health assessment Incorrect
Which type of provider organization provides management and B. Health risk assessment Correct
administrative support services to individual physicians or small C. Status assessment Incorrect
group practices in order to relieve physicians of non-medical D. History assessment Incorrect
business functions so that they can concentrate on the clinical What provides health care coverage for war veterans and their
aspects of their practice families.
Choose one answer. Choose one answer.
A. Messenger model Incorrect A. Private plans Incorrect
B. IPA Incorrect B. Veteran Affairs Correct
C. Management Services Organization Correct C. Pharmacy Incorrect
D. Open PHO Incorrect D. HMO ACT Incorrect
The Neptune Hospital provides medical care to paying patients, as Expand ASO (Context is Third Party Administration)
well as to people who either have no healthcare coverage and Choose one answer.
cannot afford to pay for the care by themselves or who receive A. Account Services Online Incorrect
services at reduced rates because they are covered under B. Account Services Only Incorrect
government-sponsored healthcare programs. To subsidize its C. Administrative Services Only Correct
treatment of these patients, Neptune has a practice of spreading D. Administrative Services Online Incorrect
these un-reimbursed costs to its other paying patients. This practice A license from the state that allows a health plan to cover health
is known as care services, is called
Choose one answer. Choose one answer.
A. antiselection Incorrect A. Certificate of Approval Incorrect
B. underwriting Incorrect B. Certificate of License Incorrect
C. cost shifting Correct C. Certificate of Authority Correct
D. receivership Incorrect D. Health License Incorrect
What does FDA stand for? The market segment composed of customers not eligible for
Choose one answer. Medicare or Medicaid who are covered under an individual contract
A. Federal Drug Administration Incorrect for health coverage, is called
B. Food and Drug Allergy Incorrect Choose one answer.
C. Food and Drug Administration Correct A. Senior market Incorrect
D. Free Dinner Access Incorrect B. Disabled market Incorrect
Which one is oldest type of CDHP account? C. Individual market Correct
Choose one answer. D. Veterans market Incorrect
A. FSA Correct A healthcare visit of any type by an enrollee to a provider of care or
B. HAS Incorrect services, is called
C. HRA Incorrect Choose one answer.
 A. Drop-in Incorrect Choose one answer.
B. Guest Incorrect A. Split panel HMO Incorrect
C. Inspect Incorrect B. closed panel HMO Correct
D. Encounter Correct C. Open panel HMO Incorrect
An HMO that combines characteristics of two or more HMO D. House panel HMO Incorrect
models is sometimes referred to as a Which one of the below is not a type of CDHP savings account
Choose one answer. Choose one answer.
A. network model HMO Incorrect A. FSA Incorrect
B. group model HMO Incorrect B. MSA Incorrect
C. staff model HMO Incorrect C. CSA Correct
D. mixed model HMO Correct D. HSA Incorrect
The parties to the contractual relationship that provides Lynwood's The insurance professionals who perform the mathematical
group health insurance to Altamaha employees are: analysis necessary for setting insurance premium rates are called
Choose one answer. Choose one answer.
A. Lynwood, Altamaha and all covered Altamaha A. Analysts Incorrect
employees Incorrect B. Professional Incorrect
B. Lynwood and Altamaha only Correct C. Statistician Incorrect
C. Lynwood and all covered Altamaha employees only D. Actuaries Correct
Incorrect Individuals who believe that they have a greater-than-average
D. Altamaha and all covered Altamaha employees only likelihood of health issues tend to seek healthcare coverage to a
Incorrect greater extent than do individuals who believe that they have an
One way that MCOs involve providers in risk sharing is by retaining average or less-than-average likelihood of loss. This tendency is
a percentage of the providers payment during the plan-year. At the known as
end of the plan year, the MCO may use the amount retained to pay Choose one answer.
for any cost overruns for referral or hospital services and any A. antiselection Correct
remaining amount will be then distributed to the providers. This risk B. proselection Incorrect
sharing method is known as C. selection Incorrect
Choose one answer. D. superselection Incorrect
A. risk pools Incorrect Deductibles, coinsurance and co-payments are examples of
B. withholds Correct Choose one answer.
C. per diems Incorrect A. passing the buck Incorrect
D. Usual Customary and Reasonable (UCR) fees Incorrect B. Cost spreading Incorrect
C. Cost sharing Correct
The dispensing of a different chemical entity within the same drug D. Cost shifting Incorrect
class of a drug listed on a pharmacy benefit management plan's When a health plan says it will not pay for your health care
formulary services, it is called
Choose one answer. Choose one answer.
A. Medical substitution Incorrect A. Denial of claim Correct
B. Specific substitution Incorrect B. Rejection of claim Incorrect
C. Direct substitution Incorrect C. Return of claim Incorrect
D. Therapeutic replacement Correct D. Payment of claim Incorrect
Which part of Medicare covers hospital Insurance? What does NPDB stands for
Choose one answer. Choose one answer.
A. Part-A Correct A. Natural Provider database Incorrect
B. Part-B Incorrect B. National Provider database Incorrect
C. Part-C Incorrect C. Native Provider database Incorrect
D. Part-D Incorrect D. National Practitioner database Correct
If employer employs more than 25 employees than employees The Military Health System of the Department of Defense offers
have choice of closed or open panel HMO. ongoing healthcare coverage to military personnel and their families
Choose one answer. through the
A. TRUE Correct Choose one answer.
B. FALSE Incorrect A. Health Care Quality Improvement Program (HCQIP)
What type of Health plan seeks to contain the costs of prescription Incorrect
drugs or pharmaceuticals while promoting more efficient and safer B. Health Plan Management System (HPMS) Incorrect
drug use C. TRICARE healthcare system Correct
Choose one answer. D. Defense Healthcare System (DHS) Incorrect
A. PPO Incorrect Utilization management techniques does not consist of:
B. HMO Incorrect Choose one answer.
C. PBM Correct A. Demand management Incorrect
D. FFS Incorrect B. Case management Incorrect
Suresh is covered by a traditional indemnity health insurance plan C. Disease management Incorrect
that specifies a $250 deductible and includes a 20% coinsurance D. Material Management Correct
provision. When Suresh was hospitalized, he incurred $2500 in The Commercial BU and the Comprehensive Health Solutions BU
medical expenses that were covered by his health plan. He are 2 Business units of WellPoint. What is third business unit of
incurred no other medical expenses during the calendar year. In WellPoint?
this situation, the amount that the insurer was obligated to pay was Choose one answer.
Choose one answer. A. Customer BU Incorrect
A. $1750 Incorrect B. Consumer BU Correct
B. $1800 Correct C. Client BU Incorrect
C. $2000 Incorrect D. Core BU Incorrect
D. $2250 Incorrect Which of the following would result in Lowering Premiums:
The HMO in which physicians are HMO employees is called 1.High Deductible
2.high Co-insurance
 3.Low Deductible Which type of health insurance plan sometimes hires its own
4.Low Co-insurance health care professionals to care only for plan members?
Choose one answer. Choose one answer.
A. Either 1 or 2? Correct A. HMO Correct
B. Only 1 Incorrect B. PPO Incorrect
C. Both 3 and 4 Incorrect C. POS Incorrect
D. Only 2 Incorrect D. FFS Incorrect
The process of identifying plan members with special healthcare The evaluation process that the physicians who are members of
needs, developing a healthcare strategy that meets those needs the IPA undergo is known as
and coordinating and monitoring care is called Choose one answer.
Choose one answer. A. orientation Incorrect
A. People Management Incorrect B. peer review Correct
B. Case Management Correct C. pooling Incorrect
C. Risk Management Incorrect D. precertification Incorrect
D. Issue Management Incorrect What does EPO stand for
Your main doctor, who provides most of your care. Also Choose one answer.
coordinates your other health care services and treatments A. Exclusive Provider Organization Correct
Choose one answer. B. Extended provider Organization Incorrect
A. MCO Incorrect C. Exclusive Patient Order Incorrect
B. DSP Incorrect D. Exclusive provider order Incorrect
C. PCP Correct The arrangement in which an employer or other group sponsor,
D. Specialist Incorrect rather than a health plan or insurance company, is financially
A list of medicines a health plan will pay for. responsible for paying plan expenses, including claims made by
Choose one answer. group plan members, is called
A. Medicine List Incorrect Choose one answer.
B. Drug Formulary Correct A. Self-paid Incorrect
C. Drug list Incorrect B. Self-funded Correct
D. Brand list Incorrect C. Self-sponsored Incorrect
A fixed dollar amount that an insured person pays before the D. On other's cost Incorrect
insurer starts to make payments for covered medical services. A type of insurance coverage that enables provider organizations
Choose one answer. to place a dollar limit on their liability for paying claims and requires
A. Co-pay Incorrect the insurer to reimburse the insured organization for claims paid in
B. Deductible Correct excess of a specified yearly maximum.
C. Co-Insurance Incorrect Choose one answer.
D. Premium Incorrect A. Stop-loss insurance Correct
In the context of Health plan marketing, which group does not B. Stop-pay insurance Incorrect
belong to non-group market segment C. Stop-profit insurance Incorrect
Choose one answer. D. Health insurance Incorrect
A. Individual market Incorrect What review program evaluates whether drugs are being used
B. Senior market Incorrect safely, effectively, and appropriately
C. Medicaid market Incorrect Choose one answer.
D. None of the above Correct A. Drug usage Review Incorrect
The amount you must pay for health services before your B. Drug Utilization Review Correct
insurance starts to pay C. Drug Usability Review Incorrect
Choose one answer. D. Dosage Utilization Review Incorrect
A. Co-pay Incorrect As Part of it Quality Management Program, Lyric Managed Care
B. Co-insurance Incorrect Organisation (MCO) regularly compares its practices and services
C. Deductible Correct with those of most successful competitor. When Lyric concludes
D. premium Incorrect that its competitor practices or services are better than its own,
Health savings accounts were created by which of the following Lyric implements the changes necessary to achieve overall quality
laws: improvement. This information indicates that Lyric assesses its
Choose one answer. performance by using a method known as
A. COBRA Incorrect Choose one answer.
B. HIPAA Incorrect A. benchmarking Correct
C. Medicare Modernization Act Correct B. positioning Incorrect
D. None of the Above Incorrect C. an adverse extent Incorrect
A health program for federal workers and their dependents. D. case-mix adjustment Incorrect
Federal workers may choose which health plan they want. An independent national organization that accredits managed care
Choose one answer. plans.
A. FEPBH Incorrect Choose one answer.
B. FEBHP Incorrect A. CMS Incorrect
C. FEPHB Incorrect B. CDHP Incorrect
D. FEHBP Correct C. NCQA Correct
A utilization management technique that requires a plan member D. Pentagon Incorrect
or the physician in charge of the member's care to notify the plan, in What do you call the cards issued by PBM to its members
advance, of plans for a patient to undergo a course of care, is Choose one answer.
called A. ID card Incorrect
Choose one answer. B. Pharmaceutical card Correct
A. Accreditation Incorrect C. License card Incorrect
B. Credentialling Incorrect D. Benefit card Incorrect
C. Pre-certification Correct In the context of Health care insurance, separation of a medical
D. None of the above Incorrect service from the basic set of benefits is called
Choose one answer.
 A. Split Incorrect C. Accreditation Commission Incorrect
B. Carve-out Correct D. American Accreditation Healthcare commission Correct
C. Outsource Incorrect
D. Separate Incorrect The most you have to pay for health services. Once you have paid
A process that determines if an already-received service was this amount, your insurance pays 100% of your health care costs.
necessary and billed properly. Choose one answer.
Choose one answer. A. Out-of-pocket maximum Correct
A. Review Incorrect B. Co-insurance Incorrect
B. Prospective review Incorrect C. Deductible Incorrect
C. Concurrent review Incorrect D. premium Incorrect
D. Retrospective review Correct In large health plans, management functions such as provider
HMO Plans are meant only for employer groups recruiting, credentialing, contracting, provider service, and
Choose one answer. performance management for providers are typically the
A. TRUE Incorrect responsibility of the
B. FALSE Correct Choose one answer.
The review and verification process to determine the current A. Managing Director Incorrect
clinical competence of the provider and whether the provider meets B. Medical Director Incorrect
the health plan C. Network Management Director Correct
Choose one answer. D. Board of Directors Incorrect
A. Appraisal Incorrect What provides health care coverage for military personnel, military
B. Credentialling Correct retirees and their dependants
C. PO Rating Incorrect Choose one answer.
D. Assessment Incorrect A. Private plans Incorrect
The market segment that is comprised largely of persons over age B. COBRA Incorrect
65 who are eligible for Medicare benefits, is called C. TRICARE Correct
Choose one answer. D. HMO ACT Incorrect
A. Supervisors market Incorrect The process of getting approval from your health plan before you
B. Veterans market Incorrect get services
C. Superiors market Incorrect Choose one answer.
D. Senior market Correct A. Pre-approval Incorrect
Expand ERISA B. Pre-authorization Correct
Choose one answer. C. Sign-off Incorrect
A. Employee Retirement Income Security Act Correct D. Referral Incorrect
B. Employee Retirement Insurance Security Act Incorrect An organization that accredits health care organizations and
C. Enterprise Regulatory Income Security Act Incorrect agencies
D. Enterprise Regulatory Insurance Security Act Incorrect Choose one answer.
Which health plan is part of traditional Indemnity health coverage? A. HMO Incorrect
Choose one answer. B. PPO Incorrect
A. Preferred provider organizations (PPO Incorrect C. JCAHO Correct
B. Physician-hospital organizations (PHO Incorrect D. COBRA Incorrect
C. Carve-outs Incorrect If the deductible were $250, the insured group member would pay
D. FFS Correct out-of-pocket the first $250 of medical expenses incurred that year
What is special about Medicare Part-D compared to other before the insurer would begin to cover any medical expenses?
Medicare plans ? Choose one answer.
Choose one answer. A. True Correct
A. Dental coverage Incorrect B. False Incorrect
B. Vision Coverage Incorrect A federally qualified HMO must accept the risk for pre-existing
C. Prescribtion drug coverage Correct conditions for all eligible employees and dependents who enroll in
D. Emergency coverage Incorrect the HMO during their initial enrollment.
Rx is used for Prescriptions, what is Dx used for? Choose one answer.
Choose one answer. A. TRUE Correct
A. Drugs Incorrect B. FALSE Incorrect
B. Diagnostics Correct Title-2 of HIPAA covers
C. Deductibles Incorrect Choose one answer.
D. Copay Incorrect A. Administrative Simplification (AS) provisions. Correct
Name the non-profit charitable organization fully funded by B. Health insurance coverage for workers and their
WellPoint families when they change or lose their jobs. Incorrect
Choose one answer. C. Administrative services only Incorrect
A. WellPoint trust Incorrect D. Haelth care quality improvement Incorrect
B. Wellpoint charity Incorrect Programs that offer drugs ordered and delivered through the mail
C. Wellpoint foundation Correct to plan members at a reduced cost, is called
D. Wellpoint plans Incorrect Choose one answer.
Title-1 of HIPAA covers A. Mail deliver pharmacy Incorrect
Choose one answer. B. Mail order pharmacy Correct
A. Administrative Simplification (AS) provisions. Incorrect C. Mail pharmacy Incorrect
B. Health insurance coverage for workers and their D. None of the above Incorrect
families when they change or lose their jobs. Correct The evaluation of health questionnaires submitted by all proposed
C. Administrative services only Incorrect plan members to determine the insurability of the group, is called
D. Haelth care quality improvement Incorrect Choose one answer.
In the context of Accreditation, URAC is also called A. Medical rating Incorrect
Choose one answer. B. Medical correction Incorrect
A. Universal resource Allocation Committee Incorrect C. Medical Underwriting Correct
B. Universal resource Accreditation Committee Incorrect
 D. Medical overwriting Incorrect The process followed to settle health insurance claims is called
In the context of Health care insurance, What does POS stand for Choose one answer.
Choose one answer. A. Claims processing Incorrect
A. Point of Sale Incorrect B. Adjudication Correct
B. Provider of Service Incorrect C. Auto-processing Incorrect
C. Patient on Sale Incorrect D. Advertisement Incorrect
D. Point of Service Correct
The process by which providers are assessed and awarded ratings A provider contract clause which states that the provider agrees to
based on a pre-defined set of standards accept the amount the plan pays for medical services as payment
Choose one answer. in full and not to bill plan members for additional amounts (except
A. Appraisal Incorrect for copayments,coinsurance, and deductibles)
B. Credentialling Correct Choose one answer.
C. PO Rating Incorrect A. No additional billing Incorrect
D. Assessment Incorrect B. No extra billing Incorrect
Which is the The federal agency that controls Medicare and C. No extra charges Incorrect
Medicaid. D. No balance billing Correct
Choose one answer. Who is the offshore BPO provider for Wellpoint that is involved in
A. FSA Incorrect the scanning of claims and converting them into an electronic
B. FEP Incorrect format.
C. HIPAA Incorrect Choose one answer.
D. CMS Correct A. UST Global Incorrect
An insurance program for people with low incomes who cannot B. Infosys Incorrect
afford health care C. CTS Incorrect
Choose one answer. D. Lason Correct
A. Medicare Incorrect In the context of Quality Management process of an MCO, which
B. Medicaid Correct one of the below is not a criteria to identify and measure quality
C. Veteran Affairs Incorrect Choose one answer.
D. TRICARE Incorrect A. Structure measures Incorrect
COB stands for: B. Outcome measures Incorrect
Choose one answer. C. Process measures Incorrect
A. Combine only Benefits Incorrect D. Framework measures Correct
B. Co-ordinate only Benefits Incorrect Case management is NOT used for which of the following options?
C. Combination of Benefits Incorrect Choose one answer.
D. Co-ordination of Benefits Correct A. High-risk case Incorrect
This plan reimburses you for your medical expenses regardless of B. Always Healthy Correct
who provides the service, although in some cases your C. High-cost case Incorrect
reimbursement amount may be limited. D. Chronic case Incorrect
Choose one answer. A computerized record of a patient's clinical, demographic, and
A. Indemnity Plan Correct administrative data, is called
B. PPO Incorrect Choose one answer.
C. MCO Incorrect A. Electronic Data Interchange Incorrect
D. POS Incorrect B. Electronic medical Record Correct
The review process in which a health plan reviews once again the C. Electrical Health record Incorrect
qualifications of the provider and verifies that the provider still D. None of the above Incorrect
meets the standards for participation in the network, is called Before an HMO contracts with a physician, the HMO first verifies
Choose one answer. the physician's credentials. Upon becoming part of the HMO's
A. re-certification Incorrect organized system of healthcare, the physician is typically subject to
B. re-credentialing Correct Choose one answer.
C. re-engineering Incorrect A. both recredentialing and peer review Correct
D. re-rating Incorrect B. recredentialing only Incorrect
_____is a nonprofit organization that accredits health plans, C. peer review only Incorrect
managed behavioral health organizations, Credentials Verification D. neither recredentialing nor peer review Incorrect
Organizations, preferred provider organizations, disease An authorization decision that is delayed is called
management organizations, and physician organizations. Choose one answer.
Choose one answer. A. Held Authorization Incorrect
A. National Committee for Quality Assurance Correct B. Pended Authorization Correct
B. International Committee for Quality Assurance Incorrect C. Postponed Authorization Incorrect
D. None of the above Incorrect
C. National Association for Healthcare Incorrect The practice of charging more for services provided to paying
D. HIPAA Incorrect patients or a third-party payer to compensate for lost revenue
Which one of the below is not a type of Utilization review? resulting from services provided free or at a significantly reduced
Choose one answer. cost to other patients is known as:
A. Prospective review Incorrect Choose one answer.
B. Concurrent review Incorrect A. Cost absorbing Incorrect
C. Retrospective review Incorrect B. Effective Cost Incorrect
D. Interim review Correct C. Cost shifting. Correct
What is the main function of a CVO D. Reduction Incorrect
Choose one answer. Which ACT provided grants and loans to start and expand a Health
A. Credentialling of providers Correct Maintenance organization
B. Utilization review Incorrect Choose one answer.
C. Authorization Incorrect A. HMO Act of 1973 Correct
D. Computation Incorrect B. HMO Act of 1976 Incorrect
 C. HIPAA Incorrect
D. ERISA Incorrect
The provision that drugs on the preferred list and those not on the
preferred list will both be covered by a PBM or health plan
Choose one answer.
A. Full formulary Incorrect
B. Closed formulary Incorrect
C. Open formulary Correct
D. None of the above Incorrect
What is MTM, in the context of health care insurance
Choose one answer.
A. Member touchpoint measures Correct
B. Mark to Market Incorrect
C. Mean time to Market Incorrect
D. Miami Texas Missourie Incorrect
When certain patients—like people who do not have health
insurance—do not have to pay for health care. Health care
providers then pass these costs to other groups of patients. This is
called
Choose one answer.
A. passing the buck Incorrect
B. Cost spreading Incorrect
C. Cost sharing Incorrect
D. Cost shifting Correct
Appropriateness of treatment provided is determined by
developing criteria that if unmet will prompt further investigation of a
claim which are also called:
Choose one answer.
A. Edits Correct
B. Checks Incorrect
C. Codes Incorrect
D. Lists Incorrect
Which ACT Prohibit a physician from referring patients to
laboratories, radiology services, medical equipment suppliers in
which the physician has a financial interest.
Choose one answer.
A. COBRA Incorrect
B. HIPAA Incorrect
C. HMO Act Incorrect
D. Ethics in Patient referrals Act Correct
One way in which a managed care plan enhances healthcare
accessibility is by
Choose one answer.
A. requiring plan members to pay coinsurance for each
service received Incorrect
B. requiring plan members to obtain all healthcare from
the plan's provider network Incorrect
C. providing a network where member's have low-cost
access to primary care Correct
D. discouraging plan members from seeking preventive
healthcare Incorrect